Potentially Infectious Waste | The University of Chicago Environmental Health and Safety

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).

Authority and Responsibility

The Biological Sciences Division (BSD), Physical Sciences Division (PSD), Pritzker School of Molecular Engineering (PME), Social Science Division (SSD) and UChicago Wellness are responsible for:

Providing rigid, leak-proof, PIW containers in buildings with on-site central storage;
Providing employees for inner building transportation in buildings with central storage locations;
Reviewing all documentation and signing manifests, only when authorized and appropriately trained;
Paying invoices and appropriating cost allocations;
Submitting manifests to Environmental Health and Safety;
Ensuring all employees have been appropriately trained per this policy;
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
Maintaining biohazard spill kits located at central storage locations.

Generators are responsible for:

Providing reusable PIW containers in buildings without on-site central storage;
Providing PIW Liners and sharps containers;
Packaging all PIW in accordance with the procedures identified in this policy;
Completing training required by this policy; and
Signing potentially infectious waste manifests at facilities without central storage ( see On-site Revmoval without Central Storage).

Office of Research Safety (ORS) is responsible for:

Providing Bloodborne Pathogens training to laboratory research personnel who work with, package, or ship potentially infectious materials; and
Confirming appropriate storage and handling of potentially infectious materials in the laboratory during laboratory inspections.

Laboratory Safety Specialists (LSS) are responsible for:

Ensuring laboratory research employees who handle, package, or ship potentially infectious materials have the appropriate training classes assigned to their training profile;
Auditing training records of laboratory personnel to ensure they have the appropriate training classes for handling potentially infectious materials;
Notifying Environmental Health and Safety (EHS) of new laboratory locations that will be generating potentially infectious waste; and
Confirming appropriate storage and handling of potentially infectious materials in the laboratory during laboratory inspections.

Environmental Health and Safety (EHS) is responsible for:

Maintaining all waste manifests from campus research activities and non-research activities (e.g., Laboratory Schools, UChicago Wellness, UCPD generated PIW);
Maintaining all waste manifests for non-clinical off-site research activities conducted at the Howard T. Ricketts Laboratory located at Argonne National Laboratory;
Providing Bloodborne Pathogens training to non-laboratory personnel (e.g., dock workers, facility managers);
Providing online Potentially Infectious Waste training for employees responsible for packaging PIW, preparing PIW containers for shipment or signing PIW manifests;
Providing online Oversized Potentially Infectious Waste Container (DOT-SP11185) training for employees who utilize or ship PIW in oversized waste containers (Stericycle 360 carts);
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;
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;
Conducting training audits of non-laboratory personnel (e.g., dock employees, facility managers) who handle and sign shipping manifests for potentially infectious waste; and
Conducting annual audits of campus central storage facilities and activities conducted at the Howard T. Ricketts Laboratory located at Argonne National Laboratory.

Training

All employees responsible for packaging, handling, transporting, storing, or preparing PIW for shipment, or employees authorized to sign potentially infectious waste manifests (e.g., select Building Managers, laboratory staff, shipping/receiving personnel); shall receive training consistent with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard and Department of Transportation (DOT) HAZMAT Employee worker training requirements.

Non-Laboratory Personnel

Training for non-laboratory personnel is provided by EHS online at ehsa.uchicago.edu. All non-laboratory personnel that are responsible for packaging, handling, transporting, storing, or preparing PIW for shipment, or employees authorized to sign potentially infectious waste manifests must take the following training classes provided by EHS within 90 days of being assigned duties relevant to PIW:

Bloodborne Pathogens (annually)
Hazard Communication (Every three years)
Potentially Infectious Waste Training (Every three years); and
Oversized Potentially Infectious Waste Container Training (Every three years) *

*Note “Oversized Potentially Infectious Waste Container Training” is only required for select employees at the Carlson Animal Resource Center or Knapp Center for Biological Discovery where Stericycle-360 carts are utilized for PIW disposal.

For questions regarding training requirements for non-laboratory personnel please contact EHS at safety@uchicago.edu.

Research/Laboratory Staff

Research personnel who sign PIW manifests must complete Potentially Infectious Waste training provided by EHS online at ehsa.uchicago.edu.

Additional training requirements for laboratory personnel are determined and provided by the Office of Research Safety (ORS). For questions regarding training requirements for laboratory personnel please contact ORS at researchsafety@uchicago.edu.

Procedure

Work Station Procedures

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

Prior to generating PIW, the generator shall obtain the appropriate PIW container and PIW liners for the disposal of PIW;
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;
All handling of infectious material and sharps by the generator shall be conducted in accordance with Universal Precautions outlined by Bloodborne Pathogens Exposure Control Program;
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;
Regular PIW, excluding sharps, shall be placed inside an appropriate PIW liner prior to placement in a PIW container
Pathological Waste shall be placed inside a PIW liner prior to placement in a PIW 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;
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 PIW container;
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;
Generators shall place the regular PIW, pathological waste, or sharps waste in reusable PIW containers provided by the division that are located in laboratories or nearby common-use rooms (e.g., autoclave rooms);
ARC manages the disposal of all infectious or unpreserved animal carcasses;
If the PIW container becomes contaminated by PIW, generators shall clean and disinfect the receptacle by following standard disinfection practices (please consult the Biological Spill Protocols document maintained by the Office of Research Safety);
Once an item is placed in a PIW container, no attempt shall be made to remove the item(s) from the waste container;
When full, all PIW liners in reusable containers shall be tied closed and the lid of the container firmly secured before the container is transported for disposal;
The room housing the workstation in which PIW 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
Biohazard spill kits shall be provided at central storage locations for potentially infectious waste.

On-Site Decontamination

Biohazardous materials (e.g., human blood or body fluids, bacterial cultures in liquid media, bodily 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 ORS.

The IEPA requires facilities that decontaminate potentially infectious materials via autoclaving to validate the decontamination process with monthly biological spore testing. Contact the Office of Research Safety at 773.834.2707 with questions regarding the validation procedure. 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.

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

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:

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;
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;
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;
If no problems are identified, the trained employee shall remove full containers and replace them with empty PIW containers for generator use;
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;
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 utilizing standard disinfection practices; and
For employees in the Animal Resource Center please refer to ARC policies and procedures for further waste handling requirements.

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:

Trained lab personnel shall package PIW in accordance with this policy;

If a container is filled or putrescent, lab personnel shall work directly with the PIW vendor or building manager to arrange for a pick-up; and

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 utilizing standard disinfection practices (please consult the Biological Spill Protocols document maintained by the Office of Research Safety).

Off-Site Removal

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

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; 

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; 

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; 

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 Medicine PIW disposal contract, as applicable, with appropriate internal organizations; and 

If the off-site location falls under the responsibility of the BSD, FPD&C shall notify the University’s Environmental Health and Safety office and provide the account number for this new location. 

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

On an established schedule, the approved disposal vendor shall pick up containers of PIW and provide clean, empty PIW containers for use; 

Prior to off-site shipment, the responsible department shall ensure staff have completed required training; 

Prior to off-site shipment, building managers and ARC staff shall verify containers are properly marked, labeled, and packaged for shipment; and 

Building managers shall also verify containers are properly loaded and secured within the transport vehicle prior to off-site shipment. 

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. Trained 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 Potentially Infectious Waste training every three years, in addition to annual OSHA required Bloodborne Pathogens training. 

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, PSD, PME, 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 EHS office at:

Environmental Health and Safety

5235 South Harper Court, 904-01

Chicago, IL 60615

.  EHS 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. 

Central Accumulation Locations

The waste removal contractual agreement for certain locations may require the potentially infectious waste to be removed from the workstation periodically and stored in a central accumulation point until removal from the University. This central accumulation point shall fall under the responsibility of the Facility Manager of the facility in which it is located. The central accumulation location(s) and the waste stored in them shall meet the following requirements: 

Store PIW in a manner and location that maintains the integrity of the package and provides protection from wind, rain and water;
Maintain the PIW in a non-putrescent state using refrigeration if necessary;
If the storage area is outdoors, such as in a trailer, the area shall be secured to prevent unauthorized access;
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;
Store the potentially infectious waste so that the materials do not become a food source or breeding place for vectors;
Containers of PIW shall not be compacted or subjected to stress that would damage the integrity of the container;
Multiple generators may use the same central accumulation point;
PIW shall be stored so as to prevent contamination of other waste or materials;
All reusable PIW 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".
Central storage locations shall be equipped with a biohazard spill kit to be used to contain spills or leaks.
If a facility wishes to add a new central accumulation location on campus EHS shall be notified in advance by the Facility Manager or Project Manager if part of a construction or renovation project.

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

Transportation

UC personnel shall not transport potentially infectious waste containers in a vehicle. 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:

Proper permitting of the vehicle by the regulating agency and the permit shall be displayed on the vehicle;
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
Compliance with all other aspects of the Department of Transportation regulations.

Emergency Response for Spills Outside of Laboratory

Immediately alert others and evacuate the area;

Restrict entry to the area and if possible post a “DO NOT ENTER” sign at entrance;

Notify the University of Chicago Police Department (UCPD) at extension 123 or 773.702.8181 to report the incident in campus buildings; and

The UCPD shall immediately notify the “On-Call” Safety Officer who will be able to direct the appropriate spill response.

Emergency Response for Laboratory Spills

Please consult the Biological Spill Protocols document maintained by the Office of Research Safety.

Reviewed: April 2021

Regulatory Citations

35 Ill. Adm. Code 1420.101-120

7-28-511-516 Municipal Code of Chicago

49 CFR 172 Subpart H