Introduction
Medical/infectious waste represents a unique category of a medical facility's solid waste stream that must be carefully monitored and controlled at all times. Despite its unique status, medical/infectious waste can be successfully integrated into solid waste management programs, including waste minimization and pollution prevention, at military installations. The purpose of this Fact Sheet is to provide a basic understanding of medical/infectious waste (as part of a medical facility's total solid waste stream), as well as its management, treatment, and disposal. The Fact Sheet also highlights applicable Federal and Air Force regulations, guidance, and policies applicable to medical/infectious waste management. Finally, the Fact Sheet discusses waste minimization and pollution prevention opportunities applicable to both medical/infectious waste and the balance of a medical facility's solid waste stream.
Medical/Infectious Waste Defined
The definition of "medical/infectious waste" provided below is adapted from Title 40 Code of Federal Regulations (CFR) Part 259, which was promulgated after enactment of the Medical Waste Tracking Act (MWTA) in 1989. The MWTA was an early demonstration effort on the part of the Federal government to regulate medical/infectious waste at the national level and formed a basis for subsequent medical/infectious waste management programs developed by each State. Part 259 has since been rescinded and removed from Title 40 CFR as obsolete. However, during recent rule-making related to air quality and controlling emissions from incinerators of medical/infectious and other waste from medical facilities ("hospital/medical/infectious waste incinerators or 'HMIWIs'"), the Environmental Protection Agency (EPA) adopted a definition of medical/infectious waste almost identical to the definition found in the former MWTA regulations. This definition, found at Title 40 CFR Part 60.51c, is presented below.
Medical/Infectious Waste means any waste which is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals, including cultures and stocks, human pathological waste, human blood and blood products, sharps and glassware, animal waste, isolation wastes, and unused sharps. A waste does not meet this definition if it is: 1) a hazardous waste identified or listed under Title 40 CFR Part 261 (e.g., certain unused chemicals and pharmaceuticals); 2) household waste as defined in Title 40 CFR Section 261.4(b)(1); 3) ash from the incineration of medical waste; 4) human remains intended for interment or cremation; or 5) domestic sewage materials identified in Title 40 CFR Part 261.4(a)(1). (NOTE: Medical/infectious waste is also commonly referred to as "Red Bag" waste.)
Although medical/infectious waste as defined above is the primary focus of this Fact Sheet, medical/infectious waste is only part of the total solid waste stream generated by a medical facility ("hospital waste"). There are many environmental and waste management concerns related to the management of hospital waste in general, not just medical/infectious waste. Some of these related waste management issues are also discussed throughout this Fact Sheet.
Major hospitals and medical facilities have been the primary focus of medical/infectious waste regulations; however, there are many other sources of medical/infectious waste. These include nursing homes, clinics, physician's offices, dental offices, laboratories, mortuaries, veterinary clinics, agricultural and animal care operations, blood banks, emergency and ambulance services, hospices, and medical/nursing schools. Most Air Force installations will have at least one source of hospital and/or medical/infectious waste.
Federal Regulatory Overview
Below are the major federal agencies and regulations that may govern the management and handling of medical/infectious waste, as well as other hospital wastes. It is important to note that in addition to applicable Federal requirements, each State may also regulate the management, tracking, and disposal of medical/infectious waste and administer applicable State public health regulations, State health codes, and State environmental regulations. Discussion of specific State programs and requirements is beyond the scope of this Fact Sheet. Individuals whose duties include the management and disposal of medical/infectious waste are encouraged to contact appropriate State authorities for guidance.
Environmental Protection Agency
The Resource Conservation and Recovery Act (RCRA)
All discarded material, including medical/infectious waste, regular noninfectious trash, and hazardous waste generated at medical facilities, is subject to regulation under the solid waste and/or hazardous waste provisions of RCRA. The EPA does not currently maintain regulations that govern medical/infectious waste as a separate or specific waste "type," however; a solid waste that meets the EPA definition of medical/infectious waste is not a hazardous waste subject to regulation under RCRA, unless it meets the definition of a hazardous waste.
It is important to note that the nonmedical/infectious portion of hospital waste may contain hazardous materials that make it subject to the hazardous waste provisions of RCRA. Examples of such materials would be certain unused pharmaceuticals, cytotoxic chemicals, laboratory chemicals, and toxic metals. EPA does not include these materials in the definition of medical/infectious waste. In most medical facilities today, waste potentially requiring regulation under the hazardous waste provisions of RCRA is routinely segregated from the medical/infectious waste and regular trash waste streams.
When pharmaceutical products that would normally require management as a hazardous waste in their "unused" state, have been "used" (i.e., completely dispensed), the empty product containers and residual product are not subject to regulation as hazardous waste, unless they are identified as an acute hazardous waste. An example would be epinephrine, which is usually administered as an injection and is listed as an acute hazardous waste (waste code P043). Containers that held an acute hazardous waste must be triple rinsed prior to disposal according to Title 40 CFR Part 261.7, "Residues of Hazardous Wastes in Empty Containers". Containers, which have residues not listed as acute hazardous waste and meet the definition of empty in Title 40 CFR Part 261.7, may be disposed of as non-hazardous solid waste.
The Clean Air Act (CAA)
Medical/infectious waste is indirectly regulated under the Clean Air Act (CAA) through the Act's standards and guidelines applicable to hospital/medical/infectious waste incinerators. These new regulations are discussed in more detail in a later section of this Fact Sheet.
Nuclear Regulatory Commission
Radioactive medical/infectious waste, most of which meets the definition of "low-level" radioactive waste (LLW) as established by the Nuclear Regulatory Commission, is generated in medical facilities as a result of administering radiopharmaceuticals and performing nuclear medicine and radioimmunology procedures. Most radioactive wastes generated in medical facilities contain short-lived radionuclides in low concentrations, and therefore are typically stored until radioactivity levels are no longer detectable, after which the waste can be managed as non-radioactive. In the Air Force, the day-to-day management of radioactive materials, including disposal, is governed by Air Force Instruction (AFI) 40-201, "Managing Radioactive Materials in the USAF." Further discussion of the management of radioactive medical/infectious waste is beyond the scope of this Fact Sheet. Additional information on the management of radioactive materials may be obtained by contacting PRO-ACT or referring to PRO-ACT's Fact Sheet "Radioactive Material Management," September 1997.
Occupational Safety and Health Administration (OSHA)
The Occupational Safety and Health Administration (OSHA) developed the Bloodborne Pathogen Standard as a means to protect the nation's workers, particularly health care workers, from exposure to the hepatitis B virus (HBV), the human immunodeficiency virus (HIV), and other bloodborne pathogens. These pathogens, as well as other organisms that cause bloodborne diseases, are found in human blood and certain other human body fluids. Although bloodborne pathogens can be found in any waste, the increased concentrations found in medical/infectious waste, and their increased resistance to antibiotics, make these pathogens a serious threat to health care personnel. Therefore, medical facility personnel involved in the generation and management of medical/infectious waste have a greater responsibility to ensure that they do not come into direct contact with blood or other potentially infectious materials during the performance of their duties. The OSHA Bloodborne Pathogen Standard establishes "Universal Precautions" (sometimes also referred to as "Standard Precautions") as an approach to infection control, wherein, all human blood and certain human body fluids are treated as if confirmed to be infectious for HIV, HBV, and/or other bloodborne pathogens. While not directly related to medical/infectious waste disposal, the requirements of the Bloodborne Pathogen Standard should be implemented when handling and preparing medical/infectious waste for disposal.
General Medical/Infectious Waste Management Steps
The steps presented below are intended to serve as a general overview of typical medical/infectious waste management practices. They are not intended as specific guidance for Air Force personnel. Each Air Force installation that is a source of medical/infectious waste will be governed by regulations, policies, and guidance administered by a variety of entities including installation medical and bioenvironmental engineering personnel, Air Force regulations, and Federal, State and local public health and environmental agencies.
Segregation of Medical/Infectious Waste
Waste generated by medical facilities is separated, as close to the point of origin as possible, into medical/infectious (Red Bag) waste, regular noninfectious trash, radioactive waste, and hazardous waste. Medical/infectious waste may be further segregated at the point of origin into "sharp" and "non-sharp" waste to accommodate varying treatment, disposal, and recycling destinations. As will be seen below in a later section of the Fact Sheet, segregation is the most important waste minimization and pollution prevention opportunity available to medical facilities.
Containerization of Medical/Infectious Waste
Proper containerization of medical/infectious waste during its collection, storage, transportation, treatment, and disposal can minimize the transfer of infectious agents, prevent injury, and facilitate the waste handling process. Medical/infectious waste should be properly containerized as close to the point of origin as possible.
Clearly marked, easily accessible containers should be provided to encourage optimal segregation by medical personnel. Markings on containers must conform with the requirements of Title 29 CFR Part 1910.1030 Paragraph (g)(1)(i). Containers should be replaced when full and carefully sealed shut. Also, containers that are to be reused should be thoroughly decontaminated before reuse and should not be used for any other purpose. Containers to be transported should be protective of transport workers. For example, sharps (glass, syringes, needles, etc.) should be placed in puncture-proof containers. Before any medical/infectious waste container or package is moved to another on-site location for storage, treatment, disposal, or repackaging, it should be clearly labeled/relabeled as medical/infectious waste.
Storage of Medical/Infectious Waste
Medical/infectious wastes may need to be stored at the facility of origin until a large enough quantity is accumulated to warrant on-site treatment, or until transport to an off-site treatment facility is scheduled. The following general guidelines apply to typical medical waste storage, transfer, and collection areas:
- Store medical/infectious waste in a designated area located at or near the treatment site or the waste pickup point.
- Areas used to store medical/infectious waste should be durable, easily cleanable, impermeable to liquids, and protected from vermin and other potential mechanisms that might spread infectious agents.
- The manner of storage should maintain the integrity of the containers, prevent leakage of waste from the container, provide protection from the weather, and maintain the waste in a non-putrescent, odorless state (this may include refrigeration).
- Storage areas should have adequate ventilation systems.
- Access should be securely controlled and limited.
Transportation of Medical/Infectious Waste
Medical/infectious waste that is not treated at the facility of origin (on-site) must be transported to an off-site treatment and/or permanent disposal facility. Each container of medical/infectious waste to be transported off-site should be clearly marked as medical/infectious waste immediately after packaging. The label or tag should also identify the generator, transporter, and date of shipment. The Department of Transportation (DoT) regulates shipments of medical/infectious wastes. Title 49 CFR Part 172, Subpart B, "Table of Hazardous Material and Special Provisions," provides detailed guidance and instructions for shipping medical/infectious wastes.
In selecting a medical/infectious waste disposal contractor, the generator should obtain as much information as possible about the contractor's operation and practices. The generator should verify that the contractor is properly permitted/licensed and in compliance with all applicable federal, state, and local regulations. The contractor should be capable of ensuring the safe containment and transport of the medical/infectious waste to its destination. State Health Departments will generally be able to provide information and guidance to generators in the selection of a suitable medical/infectious waste disposal contractor.
Treatment and Disposal of Medical/Infectious Waste
Treatment is any method, technique, or process designed to change the biological character or composition of medical/infectious waste to reduce or eliminate pathogens so that the waste no longer poses a hazard to persons who may be exposed to it. Once treatment has occurred, the resulting waste or residue is typically acceptable for disposal at a municipal-type sanitary landfill (an exception might be incinerator ash that exhibits hazardous waste characteristics). The residuals (i.e., incinerator ash or grindings) from medical/infectious waste that has been treated on-site must also be transported to a permanent disposal facility. Medical/infectious waste treatment methods are intended to achieve sterilization; the destruction of all forms of microbial life, including viruses and fungal or bacterial endospores.
Treatment methods frequently used and suitable for a variety of medical/infectious wastes are listed below:
- Chemical treatment is used primarily to treat "sharps" (after placement in a puncture-resistant leak-proof container), cultures & stocks, pathological waste, and fluid animal waste. Chemical treatment methods are selected based on the types of microorganisms likely to be present; the degree of contamination; the amount of tissue-like material present; and the type, quantity, and concentration of disinfectant used. Fluids resulting from chemical treatment are typically discharged to a sanitary sewer system. Solid residues remaining after chemical disinfection fluids are drained off are typically disposed of in a sanitary landfill. Examples of chemical disinfectants are: 1) Chlorine solutions; 2) EPA-registered virucides, bactericides, fungicides, parasiticides, and sporicides; and 3) aldehyde or phenolic compounds.
- Steam sterilization is used primarily to treat cultures & stocks, "sharps" (after placement in a puncture-resistant leak-proof container), pathological waste, isolation wastes, and animal waste. Steam sterilization uses saturated steam within a pressure vessel (also known as an autoclave) for times and temperatures sufficient to kill infectious agents within the waste. Steam sterilizers are typically operated by trained personnel.
- Incineration is used primarily to treat blood & blood products, "sharps" (after placement in a puncture-resistant leak-proof container), cultures & stocks, pathological waste, isolation wastes, and animal waste. The advantages of incinerating medical/infectious wastes are a significant reduction in waste volume and weight (up to 90 percent), assured destruction and sterilization, and the ability to manage large volumes of most types of medical/infectious wastes with little processing before treatment. Incineration converts combustible materials into noncombustible residue or ash, exhaust gases, and heat. Properly designed and operated medical/infectious waste incinerators will minimize the emission of hazardous constituents during combustion of the waste. Personnel specifically trained and certified to do so typically operate, monitor and maintain medical/infectious waste incinerators. The American Society of Mechanical Engineers (ASME) has established an EPA-sponsored certification program for operators of medical/infectious waste incineration equipment. Further information may be obtained from ASME at (212) 705-8465 or by visiting http://www.asme.org/ and clicking on "Codes and Standards."
- Encapsulation is used primarily to treat "sharps" (after placement in a puncture-resistant leak-proof container). Encapsulation involves placement of the treated waste in a polymer matrix which will solidify into a solid material. Encapsulated medical/infectious waste is typically disposed of in a sanitary landfill.
- Thermal inactivation is used primarily to treat cultures & stocks, pathological waste, and fluid animal waste. Generally used for liquid medical/infectious waste, thermal inactivation is a treatment method that uses heat to reduce infectious agents in waste. Successful treatment relies on the waste being exposed to a minimum temperature for a minimum period to ensure destruction of all pathogens. The treated and cooled liquid waste is normally discharged to the sanitary sewer.
- Discharge to a sanitary sewer system, where approved by the waste water treatment plant owner/operator and the installation Civil Engineering Environmental Flight, may be suitable as a disposal and/or treatment method for untreated bulk blood & blood products, treated animal waste fluids, and fluids resulting from chemical disinfection.
NOTE: Medical/infectious waste, including but not limited to blood, should never be discharged to a sanitary sewer without first ensuring that it is in compliance with all applicable local, State, and Federal laws. Direct (untreated) disposal to a sanitary sewer of bulk medical/infectious waste is not a preferred method. In most instances, bulk liquid medical/infectious waste should be subject to chemical treatment as mentioned above before disposal to a sanitary sewer.
Medical/infectious waste that has been rendered noninfectious by one of the above treatment methods is a "treated special waste" and is usually acceptable for disposal into a sanitary landfill (or possibly, with approval, into a sanitary sewer system, if liquid). This waste may require additional treatment, such as grinding or compaction, to reduce its volume and render it unrecognizable. Further, treated special waste must be manifested when transported.
The New HMIWI Rule
In order to implement Section 129 of the Clean Air Act, the EPA published its final rule "Air Emission Standards and Guidelines for Hospital/Medical/Infectious Waste Incinerators (HMIWIs)" in the Federal Register (62 FR 48347) on 15 September 1997. These regulations are codified in Title 40 CFR Part 60 Subpart Ce, "Emission Guidelines and Compliance Times for HMIWIs," and Subpart Ec, "Standards of Performance for HMIWIs for which Construction is Commenced after 20 June 1996." These regulations apply to incinerators whose primary purpose is the combustion of "hospital waste" and/or medical/infectious waste. Under these regulations, hospital waste means all discards generated at a hospital, including medical/infectious waste, except unused items returned to the manufacturer. Hospital waste does not include human remains intended for interment or cremation.
The EPA estimates there are approximately 2,400 HMIWIs operating in the U.S. that treat approximately 846 thousand tons of hospital and medical/infectious waste each year. Emissions from HMIWIs can contain organic compounds (dioxins/furans), particulate materials (PM), metals (cadmium, lead, and mercury), acid gases (HCl and SO2), and nitrogen oxides (NOX). These pollutants can have adverse effects on public health and welfare. The new medical waste incinerator regulations are intended to significantly reduce HMIWI emissions through the use of add-on pollution control systems. In the year 2005, the EPA will evaluate whether the residual risk to public health warrants new rule-making and additional controls.
In the new rule, HMIWIs are categorized based on waste burning capacity. A small unit burns 200 pounds per hour (lbs/hr) or less; a medium unit burns between 200 and 500 lbs/hr; and a large unit burns over 500 lbs/hr. The new rule provides emission limits for dioxins/furans, mercury, cadmium, lead, hydrogen chloride, carbon monoxide, nitrogen oxides, sulfur dioxide, and particulate matter. The rule will require the retrofitting of wet or dry "scrubber" control devices on what is expected to be almost all HMIWIs. Only HMIWIs located 50 miles outside of metropolitan areas and burn less than 2,000 pounds per week of hospital and/or medical/infectious waste will qualify for less restrictive emission limits, controls, and monitoring.
Existing incinerators must comply within three to five years of the promulgation of the new rule, depending upon when each State's implementation plan is approved by the EPA. New incinerators must demonstrate compliance with the new rule within 6 months after start-up. The EPA projects that compliance costs will result in the shutdown of most of the HMIWIs in the U.S. This is due to the extensive costs associated with retrofitting incinerators with emission controls and parameter monitoring devices, annual performance tests, and increased maintenance and administrative requirements. The high costs associated with continued incineration is why finding alternatives, as well as applying waste minimization and pollution prevention strategies to hospital or medical/infectious waste streams, is so important. Both of these strategies are discussed below.
Alternatives to On-site Incineration
Since the high cost of complying with EPA's new incinerator rule is expected to lead to the shutdown of most HMIWIs, reliance on alternative compliance techniques and technologies for users of HMIWIs will increase. Before determining alternative hospital and medical/infectious waste disposal methods, an effective and well-managed waste management plan should be established. Such a plan, which can include waste segregation, recycling, and other waste minimization and pollution prevention initiatives, should be tailored to each facility's particular waste stream makeup.
Alternative Compliance Techniques
Out-sourcing
Disposal of infectious waste through a state-licensed contractor can provide a number of advantages and is a popular alternative for many facilities. The primary concern is potential generator liability, which generally does not end when the contractor picks up the waste and exits the facility or installation.
Reclassification of the HMIWI to a "Pathological Waste" Incinerator
An incinerator that burns solely pathological waste may qualify for certain compliance exemptions in some States. (Pathological waste contains only human or animal remains.)
Reclassification of the HMIWI to a "Co-fired Combustor"
An incinerator that burns pathological waste and no more than 10 percent hospital or medical/infectious waste is considered a "co-fired combustor" and is not regulated as a HMIWI. While pathological wastes sometimes meet the definition of hospital waste or medical/infectious waste; they are viewed as "other" fuels or wastes for the purpose of this exemption.
Co-firing of Hospital and/or Medical/Infectious Waste in Another Incinerator
If available, it may be practical for hospital and/or medical/infectious wastes to be incinerated in combustors regulated under the Solid Waste Disposal Act (SWDA), or in municipal waste combustors.
Reclassification of Incinerator Size Category
Reclassifying the HMIWI to a smaller size designation can reduce the cost of add-on controls due to less stringent emission guidelines.
Alternative Treatment Technologies
Although incineration is still used to treat hospital and/or medical/infectious waste, innovative treatment technologies are increasingly being tested and adopted as alternatives or enhancements to incineration. Tighter federal controls on air emissions from medical waste incinerators are driving the search for new emission-free treatment technologies.
The EPA believes that alternative technologies for treating medical/infectious waste - e.g., steam autoclaving, microwave irradiation, macrowave irradiation, chemical treatment, thermal treatment, and biological treatment - are viable options to incineration. Issues that may affect the feasibility and selection of a particular technology can include state and local regulations, worker/public safety and health, potential environmental impact and liability, public acceptance, amount and makeup of the medical/infectious waste stream, and initial capital and operational costs.
Waste Minimization and Pollution Prevention
For waste reduction, reuse, or recycling to occur within a medical facility, it is necessary to conduct a waste audit that emphasizes characterization of the waste stream and develop a plan that promotes necessary segregation techniques along with health-care employee education/training. When performing these assessments, it will be necessary to consider the trade-offs between infection control and economic factors. For example, plastics are utilized for both products and packaging. Single-use disposable plastic items are often preferable from an infection control perspective, and they facilitate pricing patient procedures individually and make bookkeeping easier for internal and third party reimbursement. Therefore, the cost of managing the extra packaging may be offset by other benefits. Conversely, there may be situations where certain medical products can be safely sterilized and reused (e.g., linens and metal instruments), thereby reducing waste and long-term costs without compromising infection control protocols.
Pollution prevention objectives and compliance with the new hospital/medical/infectious waste incinerator rule may be facilitated by reducing the total amount of waste requiring treatment, disposal, or incineration, and by reducing the amount of mercury and dioxin-producing waste materials destined for incineration. According to the EPA, there is up to 50 times more mercury in hospital and/or medical/infectious waste than in general municipal waste. Items found in waste streams from medical facilities that may contain mercury include glass thermometers and sphygmomanometers, medical batteries, tubing weights, and amalgams. Hospital and/or medical/infectious waste that contains mercury can be kept out of a medical facility's incinerator-bound waste stream in a number of ways including: 1) Using alternative products that do not contain mercury; 2) Diverting mercury-containing products from the incinerator-bound waste stream; 3) Recycling mercury-containing products; and 4) Returning mercury-containing products to suppliers.
Packaging reduction is one of the most efficient ways to reduce waste. These efforts typically include ordering items with minimal packaging, requesting reusable/returnable containers, establishing purchasing guidelines to encourage waste prevention, and substituting less toxic materials when possible.
Certain unused, reusable medical supplies, although not degraded in any way, may require disposal under U.S. law. However, relief organizations such as AmeriCares and Carelift International pick up supplies from donating medical facilities and distribute them worldwide. Unused medical supplies and equipment suitable for donation include everything from syringes, gloves, sponges, gowns, gauze, IV tubing for kidney dialysis machines, operating room tables, wheelchairs, and X-ray units.
Recycling
Some medical facilities are adopting recycling programs as part of their waste management programs. Cardboard, food, and other general "nonmedical" hospital waste can comprise as much as 85-90 percent of a medical facility's waste stream. Corrugated cardboard, computer paper, cans and bottles can be segregated for recycling. Batteries and other noncombustible items that have usually been incinerated can also be segregated for recycling.
Defense Reutilization and Marketing Offices (DRMOs) may be able to accept certain non-infectious items recovered from waste streams including heavy metals. It is recommended that medical facilities and installations coordinate with their local waste management planning officials and DRMO representatives to evaluate the viability of this option.
Sound waste management practices, including segregation and isolation, can limit the potential for cross-contamination of recyclable non-infectious wastes with non-recyclable infectious waste, and increase the total portion of a medical facility's waste stream available for recycling. Expired or otherwise unusable medications can sometimes be returned to the manufacturer. In addition, many suppliers will take back (backhaul) pallets, shipping containers, pill bottles, and other packaging.
The Environmental Quality Directorate, Headquarters Air Force Center for Environmental Excellence (HQ AFCEE/EQ), is in the process of developing a Pollution Prevention Opportunity Assessment Model Shop Report for Medical Facilities. When completed, this report will assist installations with identifying and implementing pollution prevention opportunities targeted specifically to Air Force medical center, hospital, and clinic operations. PRO-ACT will announce the completion and availability of the Medical Facility Model Shop Report in a future edition of our CrossTalk publication.
For More Information...
Document References
- "Managing and Tracking Medical Wastes," September 1989, EPA/530-SW-89-021.
- "Model Guidelines for State Medical Waste Management," 1992, The Council of State Governments.
- "EPA Guide for Infectious Waste Management," May 1986, EPA/530-SW-86-014.
- "Medical Waste Incinerators: Alternative Techniques and Technologies," October 1997, MSgt Kurt Jagielski, Det 1, HSC/OEBQ.
- "New Medical Waste Incinerator Rule," October 1997, MSgt Kurt Jagielski, Det 1, HSC/OEBQ.
- "FACT SHEET: New Hospital/Medical/Infectious Waste Incinerators," EPA Office of Air Quality.
- "FACT SHEET: Existing Hospital/Medical/Infectious Waste Incinerators," EPA Office of Air Quality.
- "FACT SHEET: Air Emission Standards and Guidelines for Hospital/Medical/Infectious Waste Incinerators," EPA Office of Air Quality Planning and Standards.
- "Donating Medical Supplies: Saving Money, Saving Lives," Winter 1998 Edition, EPA's Reusable News Newsletter.
- "FACT SHEET: Mercury in Medical Waste - Keeping Mercury Out of Medical Waste," EPA Region 5, Air and Radiation Division, http://earth1.epa.gov/docs/ARD-R5/glakes/hgfact.htm.
- "FACT SHEET: Mercury in Medical Waste - Use of Alternative Products," EPA Region 5, Air and Radiation Division, http://earth1.epa.gov/docs/ARD-R5/glakes/hgfact.htm.
- "EPA Sets Final Rule to Significantly Cut Harmful Air Pollution from Medical Waste Incinerators," HQ USEPA Press Release, 15 August 1997.
- "Radioactive Material Management," September 1997, PRO-ACT Fact Sheet, http://www.afcee.brooks.af.mil/pro_act/pro_acthome.asp.
- "Standards of Performance for New Stationary Sources and Emission Guidelines for Existing Sources: Hospital/Medical/Infectious Waste Incinerators; Final Rule," Federal Register: September 15, 1997 (Volume 62, Number 178), Page 48347.
- "Standards of Performance for New Stationary Sources," Title 40 CFR Part 60.
- "Finding the Rx for Managing Medical Waste," September 1990, U.S. Congress, Office of Technology Assessment, OTA-O-459.
- "Pollution Prevention Opportunities at Medical Treatment Facilities," August 1997, Eric Haukdal and 1Lt Lisa Strutz, U.S. Army CHPPM.
- "Hazardous Materials Tables, Hazardous Materials Communication Requirements and Emergency Response Information Requirements," Title 49 CFR Part 172.
- "Occupational Safety and Health Standards," Title 29 CFR Part 1910.
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