ANA House of Delegates Report: Report: Reduction of Health Care Production of Toxic Pollution

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SUBJECT: Reduction of Health Care Production of Toxic Pollution

INTRODUCED BY: Elizabeth Carney, RN, MSN, OCN, ANP
President, Vermont State Nurses Association

ACTION: The 1997 ANA House of Delegates agreed to:

  1. Endorse the position statement on regulated medical waste as published by the Association of Operating Room Nurses.
  2. Collaborate with other organizations to develop federal and state standards for:
    • a. dioxin emission from medical waste incinerators
    • b. PVC product alternatives
    • c. mercury-free health care facilities
    • d. non-incineration methods of medical waste disposal
    • e. by-products from the use of lasers or electrosurgical units
  3. Educate registered nurses and other health care personnel about medical waste issues.
EXECUTIVE SUMMARY: The following report urges the House of Delegates to support the definition of regulated medical waste as developed by the Association of Operating Room Nurses; to lobby for medical waste incinerator dioxin emissions to be less than 0.1 ng TEQ/dscm; to promote alternatives to products made of PVC; to support mercury free health care delivery and facilities; to support non-incineration methods of medical waste disposal; and to educate nurses and other health care personnel about these issues.

The Vermont State Nurses Association recommended that the 1997 ANA House of Delegates:

  1. Adopt the definition of regulated medical waste as developed in a collaborative meeting convened by the Association of Operating Room Nurses in 1992: Regulated medical waste shall include sharps; cultures and stocks of infectious wastes; animal waste; selected isolation waste; pathological waste; and human blood, blood products, body fluids (Association of Operating Room Nurses, 1997).
  2. Support and lobby for dioxin emission standards for medical waste incinerators to be at least as rigorous as those for hazardous waste incinerators with the desired outcome to be emissions of no greater than 0.1 ng TEQ/dscm.
  3. Promote use of alternatives to PVC products.
  4. Commit to mercury-free health care facilities and delivery by the year 2000.
  5. Promote use of non-incineration methods of disposal for all health care wastes that can be safely disposed of in other ways.
  6. Educate registered nurses and other health care personnel about the issues discussed in recommendations #1-5.


The founder of modern nursing, Florence Nightingale described components required for good nursing care. Included was a healthy environment (Nightingale, 1926). We now find ourselves in an ethical dilemma. Our provision of care is not only making health care workers ill (1995 ANA House of Delegates), the disposal of the byproducts of that care is imposing significant risk for the general public. "U.S. hospitals alone, are responsible for over 6600 tons of waste per day, 1% of all the waste generated in America (Shaner, 1996). The United States Environmental Protection Agency has identified medical waste incinerators as a major contributor of dioxin to the environment. That does not include the waste associated with health care outside of hospitals. The incineration disposal of medical waste is making people sick. It is one thing to look at a therapy knowing that there are risks inherent in the treatment and weigh the benefit versus the risk. It is something entirely different to unnecessarily create risk for both the provider and the general consumer because we haven't evaluated what we are doing.

Cost cannot be an excuse for not doing the right thing since many of the possible changes can actually decrease the cost of the provision of care. The process of providing care produces an enormous amount of waste that needs to be disposed of. In mistaken efforts to protect the public most medical waste, that is, the waste generated in the provision of illness and health care has been incinerated. Incineration releases significant toxins into the environment. A particularly dangerous toxin is dioxin. Dioxin was declared a potent human carcinogen by the International Agency of Cancer Researchers in February 1997. Additionally, we have continued to unnecessarily use instruments and products containing heavy metals, for example, mercury, a known neurotoxin.

Regulated Medical Waste

There are several categories of waste from health care facilities. These include:

  • solid waste, or regular trash,
  • regulated medical waste, items such as needles, body parts, cultures and stocks, and blood saturated items, and
  • hazardous wastes, i.e., items such as chemical waste, and solvents.

Not all potentially infectious waste needs to be incinerated. The "must be incinerated" waste is a mere fraction of the total amount of regulated medical waste. Hospitals and other health care systems need to segregate their wastes appropriately to reduce the amount of regulated medical waste generated which then requires special treatment. The only segment of regulated medical waste that needs to be treated by incineration is pathologic waste and EPA regulated pharmaceuticals. The remainder of regulated medical waste can be safely treated with alternative technologies.

Regulated Medical Waste, can be divided into six categories:

  • sharps,
  • cultures and stocks of infectious wastes,
  • animal waste,
  • selected isolation waste,
  • pathological waste, and
  • human blood, blood products, and body fluids.

The first four categories are included in current definitions of regulated medical waste because of risk they pose to public health and the environment (AORN, 1997).

Following are the definitions of the categories of regulated wastes as described in the AORN document "Regulated Medical Waste Definition and Treatment: A Collaborative Document" (1997) which is reprinted in Attachment A.

  • Sharps (used and unused) are "discarded medical devices that have been used in animal or human patient care, medical research, or industrial laboratories and that are capable of puncturing or cutting the skin, thereby creating a portal of entry".
  • Cultures and stocks of infectious wastes "includes human and animal cell cultures from medical and pathological laboratories; cultures and stocks of infectious agents from research and industrial laboratories; wastes from the production of biologicals; discarded live and attenuated vaccines; and culture dishes and devices used to transfer, inoculate, and mix cultures of infectious agents".
  • Animal waste is "discarded material originating from animals inoculated with infectious agents during research or production of biological or pharmaceutical testing".
  • Selected isolation waste consists of "biological waste and discarded materials contaminated with blood, excretion, exudates, or secretions from humans who are isolated to protect others from certain highly virulent diseases (i.e., class 4 etiologic agents) or from isolated animals known to be infected with these diseases".
  • Pathological waste is "discarded pathological wastes (e.g., human tissues, organs, body parts) removed during surgery, autopsy, or other medical procedures".
  • Human blood, blood products, body fluids "includes discarded free-flowing human blood and blood products (e.g.. plasma, serum) any free-flowing body secretion containing blood components".

Regulated medical waste can be disinfected by heat, chemical treatments, or radiation. Only pathological waste may require incineration; however, in many states it can also be buried.


"Dioxins are a family of chemicals with related properties and toxicity. There are 75 different forms of dioxin, the most toxic of which is 2,3,7,8-tetrachlorodibenzo-p-dioxin, or TCDD" (Gibbs, 1995). As in the previously cited publication our use of the term "dioxin" will mean the most toxic forms of dioxin. Dioxin is not a substance that is deliberately manufactured for some purpose. It is a byproduct of industrial processes which use chlorine or bromine or it occurs when organic substances in the presence of chlorine are burned (Gibbs, 1995). In the health care setting, it means that when all of that waste which is inappropriately burned, e.g., I.V. solution bags and tubing, dioxin is released. Other plastics and products, which could be recycled, but are indiscriminately burned, release other toxins as well, e.g., some, but not all, of the red plastic bags use cadmium to make them red. Cadmium is toxic to male reproductive function in animals and human placentas, causes birth defects in animals and damages developing human lungs and may predispose infants to Respiratory Distress Syndrome (Greater Boston Physicians for Social Responsibility and Massachusetts Public Interest Research Group Education Fund, 1996).

The problems with dioxin overwhelm the toxic effects caused by many other byproducts of incineration because of the amount produced, and the insidiousness and amount of damage caused by blood levels almost too low to detect. "Peer reviewed research has documented that dioxin causes cancer, affects the immune system, causes birth defects-including fetal death-decreases fertility, causes female and male reproductive dysfunction, and affects a variety of hormonal processes involving insulin, thyroid hormones, and steroid hormones" (US Environmental Protection Agency, 1994 as summarized in Environmental Working Group, 1997). The serious public health implications of dioxin were recognized by the American Public Health Association in the adoption of their resolution titled: "Prevention of Dioxin Generation from PVC Plastic Use of Health Care Facilities" in November 1996. The resolution focused on the elimination of PVC products in hospital settings because of the quantity used and the generation of dioxin when these products are incinerated. PVC products in hospitals include IV bags, blood bags, and tubing.

The EPA is adopting standards for the emission of dioxin from medical waste incinerators. Those standards will probably have been released by the time of the 1997 ANA House of Delegates. Presently more than two thirds of medical waste incinerators use NO pollution control (EWG, 1997, p. 27). Ironically, the level being considered for medwaste incinerators, between 2.3 and 15.0 ng TEQ/dscm compares to 0.2 ng allowed in hazardous waste incinerators. It is unacceptable to permit the medical waste incinerators of hospitals, places which should promote health, to adhere to weaker standards than hazardous waste incinerators.

Living within two miles of medical waste incinerators are the following:

  • 5.6 million children
  • 15 percent of people of color; 7% of whites.
  • 14% of Americans who live below the poverty line.

(EWG, 1997)


Mercury is a heavy metal which readily moves from a solid to liquid to a gaseous state. Mercury has long been known as a neurotoxin. (Remember the Mad Hatter in Alice in Wonderland?) Is there a nurse who hasn't cleaned up the mercury after breaking a thermometer? Because of the volatility of mercury, vapor may be inhaled in the process of cleaning up that mercury. Up to 80% of inhaled mercury is absorbed in the bloodstream and can cause poisoning and respiratory problems (Shaner, 1996). All mercury should be treated as hazardous waste.

An even more satisfactory approach in dealing with mercury is to work for a mercury free workplace. There are substitutes for the products used in health care which contain mercury, e.g., thermometers, blood pressure monitoring devices, and Miller-Abbott Cantor Tubes. Using the year 2000 as a goal allows time for phase-in of mercury free products.

Registered Nurses must be involved in preventing iatrogenic pollution.


  • American Public Health Association. (November, 1996). Resolution: Prevention of dioxin generation from PVC plastic use by health care facilities. Washington, DC: Author.
  • Association of Operating Room Nurses (1997). Regulated medical waste definition and treatment: A collaborative document. Standards, Recommended Practices, and Guidelines, 33-38. Denver, CO: Association of Operating Room Nurses, Inc.
  • Environmental Working Group. (1997). First do no harm: Reducing the medical waste threat to public health and the environment. Washington, DC: Author.
  • Gibbs, L.M. and the Citizens Clearinghouse for Hazardous Waste (1995). Dying from dioxin: A citizen's guide to reclaiming our health and rebuilding democracy. Boston: South End Press.
  • Greater Boston Physicians for Social Responsibility and the Massachusetts Public Interest Research Group Education Fund (1996). Generations at risk: How environmental toxins may affect reproductive health in Massachusetts. Boston: Greater Boston Physicians for Social responsibility.
  • Nightingale, F. (1926 ). Notes on nursing: What it is, and what it is not. New York and London: D. Appleton and Company.
  • Shaner, H. (1996) . Pollution prevention for nurses: Minimizing the adverse environmental impact of health care delivery. Vermont Registered Nurse, 62(4), 1-2, 8-9.
  • US Environmental Protection Agency. (1994). Health assessment document for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and related compounds. External review draft (EPA/600/BP-92/001a-c). Washington, DC: Author.
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