Potentially Infectious Waste

Policy

All potentially infectious waste (PIW) generated at the University of Chicago shall be treated and/or disposed of in accordance with applicable regulations.  The removal of potentially infectious waste from the University of Chicago, University of Chicago Medicine, Animal Resource Center (ARC), and off-site locations shall be facilitated by a contracted service, which is licensed, bonded, and permitted by the Illinois Environmental Protection Agency (IEPA).

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Authority and Responsibility

The Biological Sciences Division (BSD), Institute of Molecular Engineering (IME), Physical Sciences Division (PSD), and Social Science Division (SSD) are responsible for:

  1. Providing rigid, leak-proof, reusable containers labeled with either the international biohazard symbol or with the words “Infectious Waste” on the lids or sides so as to be readily visible in buildings with on-site central storage;
  2. Providing employees for inner building transportation in buildings with central accumulation locations;
  3. Reviewing all documentation and signing manifests, only when authorized and appropriately trained;
  4. Paying invoices and appropriating cost allocations;
  5. Submitting manifests to Environmental Health and Safety;
  6. Ensuring all employees have been appropriately trained;
  7. Notifying assigned Laboratory Safety Specialist and the Office of Research Safety (ORS) when a new principal investigator will be working with potentially infectious materials; and
  8. Maintaining biohazard spill kits located at central accumulation locations.

Generators are responsible for:

  1. Providing rigid, leak-proof, reusable containers labeled with either the international biohazard symbol or with the words “Infectious Waste” on the lids or sides so as to be readily visible in buildings without on-site central storage;
  2. Providing red plastic liners and sharps containers;
  3. Packaging all PIW in accordance with the procedures identified in this policy; and
  4. Taking required training.

Office of Research Safety (ORS) is responsible for:

  1. Providing Bloodborne Pathogens training to laboratory research personnel who work with, package, or ship potentially infectious materials;
  2. Providing Department of Transportation training to laboratory research personnel who sign potentially infectious medical waste manifests; and
  3. Confirming appropriate storage and handling of potentially infectious materials in the laboratory during laboratory inspections.

Laboratory Safety Specialists (LSS) are responsible for:

  1. Ensuring laboratory research employees who handle, package, or ship potentially infectious materials have the appropriate training classes assigned to their Combined Access Training Tracking System (CATTS) or equivalent profile;
  2. Confirming training audits of laboratory personnel to ensure they have the appropriate training classes for handling potentially infectious materials;
  3. Notifying Environmental Health and Safety (EHS) of new laboratory locations that will be generating potentially infectious waste; and
  4. Confirming appropriate storage and handling of potentially infectious materials in the laboratory during laboratory inspections.

Environmental Health and Safety (EHS) is responsible for:

  1. Maintaining all waste manifests from campus research activities and non-research activities (e.g., Laboratory Schools, UCPD generated PIW);
  2. Maintaining all waste manifests for non-clinical off-site research activities conducted at the Howard T. Ricketts Laboratory located at Argonne National Laboratory;
  3. Providing Bloodborne Pathogens training to non-laboratory personnel (e.g., dock workers, facility managers);
  4. Providing program oversight for campus locations and non-clinical off-site research activities conducted at the Howard T. Ricketts Laboratory located at Argonne National Laboratory;
  5. Conducting quarterly training audits of employees signing manifests for campus locations and non-clinical off-site research activities conducted at the Howard T. Ricketts Laboratory located at Argonne National Laboratory;
  6. Conducting training audits of non-laboratory personnel (e.g., dock employees, facility managers) who handle potentially infectious waste; and
  7. Conducting annual audits of campus central storage facilities and activities conducted at the Howard T. Ricketts Laboratory located at Argonne National Laboratory.

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Procedure

Work Station Procedures

All handling, segregating, packaging, labeling, and storing of PIW shall be done in accordance with the procedures listed below:

  1. Prior to generating PIW, the generator shall obtain the appropriate disposal container for the disposal of PIW;
  2. Unless otherwise indicated in a written lab specific biosafety plan, plastic liners shall be a red in color and clearly labeled with the international biohazard symbol or the words “Infectious Waste”.  All bags used shall be impervious to moisture and of strength sufficient to preclude tearing, ripping, or bursting under normal conditions of usage and handling;
  3. All handling of infectious material and sharps by the generator shall be conducted in accordance with appropriate procedures and good practice;
  4. Once infectious material or other items (e.g., unused sharps) are to be disposed, the generator shall properly segregate the PIW from all other waste and place it in the appropriate container. If PIW becomes mixed with any other waste, all of the waste shall be treated as PIW;
  5. Regular PIW excluding sharps shall be placed inside an appropriate plastic liner prior to placement in a rigid, leak-proof, reusable container labeled with either the international biohazard symbol or with the words “Infectious Waste” on the lids or sides so as to be readily visible;
  6. Pathological Waste shall be placed inside an appropriate plastic liner prior to placement in a black reusable container. Chemical preservatives (e.g., formaldehyde) shall be disposed of separately from the pathological waste prior to placement in the liner. Preservatives shall be disposed of as chemical waste;
  7. Sharps shall be placed in a red sharps container identified with the words "Biohazard/Sharps" and display the biohazard symbol. Once the sharps container is full (no greater than three-quarters full), it shall be closed and placed inside a rigid, leak-proof, reusable container labeled with either the international biohazard symbol or with the words “Infectious Waste” on the lids or sides so as to be readily visible;
  8. Over-sized PIW shall be addressed on a case-by-case basis and generators shall contact the appropriate building manager to arrange for packaging and disposal;
  9. Generators shall place the regular PIW, pathological waste, or sharps waste in reusable containers provided by the division that are located in laboratories or nearby common-use rooms (e.g., autoclave rooms);
  10. ARC manages the disposal of all infectious or unpreserved animal carcasses;
  11. All personnel utilizing oversized biohazard “360-Carts” shall take additional DOT SP-11185 training on how to appropriately package, mark, and ship the carts;
  12. If the PIW container becomes contaminated by PIW, generators shall clean and disinfect the receptacle by wiping down or immersing the surface in a freshly made 10% bleach solution (1:10 dilution or one part bleach to nine parts water);
  13. Once an item is placed in a reusable container, no attempt shall be made to remove the item(s) from the waste container;
  14. When full, all liners in reusable containers shall be tied closed and the lid of the container firmly secured before the container is transported for disposal;
  15. The room housing the work station in which potentially infectious waste or agents known to be infectious to humans is used or stored shall be identified by signage affixed with the universal biohazard symbol warning unauthorized individuals of the potential infection risk danger; and
  16. Infectious waste spill kits shall be provided at central storage locations for potentially infectious waste.

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On-Site Decontamination

Biohazardous materials (e.g., human blood or body fluids, bacterial cultures in liquid media, body fluids or animals experimentally infected with pathogens) may be decontaminated by autoclaving or treating with an appropriate chemical disinfectant for the sufficient contact time that is proven to decontaminate the biohazardous material and is approved by the Office of Research Safety. The IEPA requires facilities that decontaminate potentially infectious materials via autoclaving must validate the decontamination process with monthly biological spore testing. Contact the Office of Research Safety at 773.834.2707 with questions. After decontamination, liquids may be disposed of by pouring them down the drain to the sanitary sewers and then flushing the drain with copious amounts of water.

Do not autoclave materials containing solvents, radioactive material, volatile or corrosive chemicals (e.g., formalin, bleach, chloroform, phenol) due to the possibility of dangerous gases being produced. Trace amounts of bleach used to decontaminate laboratory materials during procedures (e.g., decontaminating pipette tips or other laboratory ware) may be autoclaved.

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On-Site Removal with Central Storage

In buildings with a central storage location, on-site removal of PIW shall be conducted in accordance with the procedures listed below:

  1. On a regular basis, trained employees shall remove and transport full containers to a central storage area within buildings for future pick-up and replace them with empty containers for generator use;
  2. If a new container(s) is needed prior to a regular pick-up or a container is putrescent, generators shall contact the appropriate building manager who will make arrangements to provide an additional container to replace the full/malodorous container;
  3. Prior to removing a container, trained employees shall visually verify appropriate closure of liners/sharps containers, proper segregation of waste, and closure of reusable container(s). Trained employees shall not sort through the waste to confirm these items;
  4. If no problems are identified, the trained employee shall remove full containers and replace them with empty containers for generator use;
  5. If problems are identified, trained employees will not remove the container. The trained employees shall provide empty containers so as not to impede proper disposal of newly generated waste, attach a notice to the unacceptable container identifying the problems and notify the appropriate building manager of the unacceptable container. The building manager shall contact the generator to resolve the matter;
  6. If the PIW container becomes contaminated by PIW or leaks during transport, the trained employee shall clean and disinfect the receptacle and affected area by wiping down or immersing the surface in a freshly made 10% bleach solution (1:10 dilution or one part bleach to nine parts water); and
  7. Refer to ARC policies and procedures for the vivaria.

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On-Site Removal without Central Storage

In buildings without a central storage, location on-site removal of PIW shall be conducted in accordance with the procedures listed below:

  1. Trained lab personnel shall package PIW in accordance with this policy;
  2. If a container is filled or putrescent, lab personnel shall work directly with the vendor or building manager to arrange for a pick-up; and
  3. If the PIW container becomes contaminated by PIW or leaks during transport within the laboratory, the trained employee shall clean and disinfect the receptacle and affected area by wiping down or immersing the surface in a freshly made 10% bleach solution (1:10 dilution or one part bleach to nine parts water).

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Off-Site Removal

The responsibility for off-site disposal shall be determined as listed below:

  1. All off-site locations to be occupied by BSD or University of Chicago Medicine (UCM) operations shall be evaluated by UCM/BSD Facilities, Facilities, Planning, Design, and Construction (FPD&C) for the potential to generate PIW. This evaluation should happen during the program and off-site lease development process;
  2. If during program and lease development it is determined that PIW will be generated, the responsibility for PIW disposal between the building owner/lease agent and BSD or University of Chicago Medicine shall be clearly delineated. This information will be documented in the Off-site Property Onboarding Checklist and Service Responsibility Matrix for the location;
  3. For off-site locations where clinical/medical activities are conducted and either BSD or University of Chicago Medicine is determined to be responsible for PIW disposal, generation and disposal shall be completed in accordance with the policies of the University of Chicago Medicine. For non-clinical off-site research activities conducted at the Howard T. Ricketts Laboratory located at Argonne National Laboratory, generation and disposal shall be completed in accordance with the policies of the University of Chicago;
  4. For those off-site locations at which BSD or University of Chicago Medicine is determined to be responsible for PIW disposals, FPD&C will coordinate adding the new off-site location to the University of Chicago's or University of Chicago Medical Center's PIW disposal contract, as applicable, with appropriate internal organizations; and
  5. If the off-site location will be added to the University of Chicago PIW disposal contract, FPD&C shall notify the University’s Environmental Health and Safety office.

Off-site removal shall be conducted in accordance with the procedures listed below:

  1. On an established schedule, the approved disposal vendor shall pick up containers of PIW and provide clean, empty containers for use;
  2. Prior to off-site shipment, the responsible department shall ensure staff have completed required training;
  3. Prior to off-site shipment, building managers and ARC staff shall verify containers are properly marked, labeled, and packaged for shipment; and
  4. Building managers shall also verify containers are properly loaded and secured within the transport vehicle prior to off-site shipment.

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Manifests

All documentation shall be processed in accordance with the procedures below.

Only trained department staff, dock workers, building managers, or ARC staff shall review all documentation associated with the shipment prior to the vendor leaving the building. Department staff, dock workers, building managers, or ARC staff shall sign the Potentially Infectious Medical Waste Manifest only after the review is complete and accuracy of the Manifest information is verified. All employees signing Illinois Potentially Infectious Medical Waste Manifests shall be trained in Shipping Hazardous Materials – General Awareness every three years.

Department staff, building managers, or ARC staff, including those at off-site locations shall forward the Generator Copy (Copy 4) of the manifest to a designated office within their Division (e.g., BSD, IME, PSD, SSD). After receipt of the “Designated Facility Mail to Generator” copy (Copy 1) of the manifest stamped with “DESTRUCTION VERIFIED” as well as the invoice from the vendor, the designated office will then forward both copies of the manifest to Environmental Health and Safety.  Environmental Health and Safety shall review and retain the manifests for a period of three years commencing with the date noted on the manifest indicating when the waste was shipped. Invoices shall not be processed by the designated office until the stamped Copy 1 of the manifest has been obtained. If Copy 1 of the manifest has not been received within 35 days of shipment the department shall contact the term waste vendor to notify them or obtain a copy electronically via the vendor’s online portal.

The disposal vendor is responsible for sending the invoices to the appropriate designated office(s). These designated offices will coordinate reimbursement from appropriate departments via University procedures.

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Storage

Bulk Storage

If under a waste removal contractual agreement, the potentially infectious waste is to be removed from the work station periodically and stored in a central accumulation point to await removal from the University. The central accumulation point(s) and the waste stored in them shall meet the following requirements:

  1. Store the potentially infectious waste in a manner and location that maintains the integrity of the package and provides protection from wind, rain and water;
  2. Maintain the potentially infectious waste in a non-putrescent state using refrigeration if necessary;
  3. If the storage area is outdoors, such as in a trailer, the area shall be secured to prevent unauthorized access;
  4. Limit access to on-site storage areas to authorized persons only by securing the room. The central accumulation point shall also be identified by signage that reads "Biohazard" and displays the biohazard symbol;
  5. Store the potentially infectious waste so that the materials do not become a food source or breeding place for vectors;
  6. The packages of potentially infectious waste shall not be compacted or subjected to stress that would damage the integrity of the container;
  7. Multiple generators may use the same central accumulation point;
  8. Potentially infectious waste shall be stored so as to prevent contamination of other waste or materials;
  9. All reusable containers or facility equipment (e.g., carts, squeegees or shovels) which are visually contaminated with PIW shall be cleaned in a designated area; and signage identifying the storage operation shall be prominently displayed at the points of access to the secured storage area. Signs shall be marked in lettering that is readable at a minimum distance of five feet. At a minimum, the signs shall display the International Biohazard Symbol and the word "biohazard".
  10. Central storage locations shall be equipped with a bloodborne pathogens spill kit to be used to contain spills or leaks.

All bulk storage areas shall be inspected on an annual basis by the appropriate safety office responsible for oversight using the Medical Waste Storage Area Inspection Form.

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Transportation

Since a contracted removal service shall be used for the transportation of PIW from the point of generation to the treatment facility or transfer station, the transporter shall provide the following:

  1. Proper permitting of the vehicle by the regulating agency and the permit shall be displayed on the vehicle;
  2. Provide the generator with a completed manifest for signature. After signing the manifest, the transporter shall provide the generator one copy; upon arriving at the treatment facility, the transporter shall retain a copy and give the remaining two copies of the manifest to the treatment facility; the facility treating the waste shall keep one copy of the manifest and return the final copy to the generator; and
  3. Compliance with all other aspects of the Department of Transportation regulations.

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Infectious Agent Spill Response

All potentially infectious agent spills shall immediately be contained and cleaned up by employees properly trained and equipped to work with microorganisms known to be infectious or potentially infectious to humans, animals, or plants.

Do NOT attempt to clean up a spill if any of the following conditions apply:

  • The spill is an unknown agent;
  • The quantity spilled is greater than one liter;
  • A secondary emergency situation exists (e.g., fire); or
  • You are uncomfortable in the situation.

If you are UNABLE to deal with the spills, adhere to the following steps:

  • Immediately alert others and evacuate the area;
  • Post a “DO NOT ENTER” sign on the door;
  • Notify the University of Chicago Police at extension 123 or 773.702.8181 to report the incident in campus buildings or Public Safety at 773.702.6262 for the University of Chicago Medicine; and
  • The University Police shall immediately notify the “On-Call” Safety Officer.

If you are ABLE to clean up the spill without assistance, adhere to the following steps:

  • If the spill occurs inside a biosafety cabinet (BSC): Immediately stop all work, leave the BSC blower fan on, and notify your supervisor;
  • If the spill occurs outside a BSC: Remove contaminated personal protective equipment (PPE) and/or clothing and place into a biohazard bag, wash all contaminated body parts, and flush exposed mucous membranes with water;
  • If the agent is capable of causing infection via the aerosol route: Notify others, leave the lab immediately, and wait at least 20 minutes prior to re-entry to allow aerosols to dissipate;
  • Clean up the spill following the procedures below:
  1. Put on gloves and appropriate PPE including eyewear, lab coat, mask, or face shield (if splashing is likely);
  2. Cover the spill with paper towels and carefully pour or spray a freshly made bleach solution to achieve a 1:10 dilution or one part bleach to nine parts water final concentration onto the paper towels, into the drain pan for Type II BSCs if spill occurred inside of a BSC, and any contaminated laboratory equipment;
  3. Remove any broken glass or sharp objects from the spill using mechanical means (e.g., forceps, hemostats, needle nose pliers, broom and dust pan). Never remove sharps/broken glass by hand;
  4. After ten minutes of contact time with the disinfectant, wipe down the contaminated surface including the walls of the BSC (if the spill occurred inside of a BSC) and any contaminated equipment;
  5. Remove the contaminated paper towels and place them into a biohazard bag for appropriate disposal;
  6. Repeat the process until all visible contamination is removed;
  7. Spray the surface with 70% ethanol/isopropyl alcohol to remove residual disinfectant as bleach can be corrosive;
  8. Remove all PPE and immediately wash hands; disinfect, launder and/or discard contaminated PPE as necessary; and
  9. Notify your designated Laboratory Safety Specialist and the Office of Research Safety.

Please consult the Office of Research Safety at 773.834.2707 for additional guidance or assistance.

Reviewed: October 2016

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Regulatory Citations

35 Ill. Adm. Code 1420.101-120

7-28-511-516 Municipal Code of Chicago

49 CFR 172 Subpart H

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