Environmental Services
Professional Training
Course
Acknowledgments
This course was developed for the District of Columbia
Hospital Association (DCHA) in collaboration with the District
of Columbia Department of Health and the Food and Drug
Administration. The Food and Drug Administration, Division
of Facilities Planning, Engineering and Safety generously
provided time, personnel, and resources for this project. The
District of Columbia Department of Health provided funding
to pay for the course materials. The author wishes to thank
all those who graciously gave their time to provide comments
and technical assistance during the development of this
course.
Table of Contents
Course Objective
Pre-Test
1.0 Overview of Occupational Hazards
2.0 Microorganisms & Infectious Agents
3.0 Infectious Waste
4.0 Cleaning for Health
5.0 Hazardous Material Safety
6.0 Needlestick and Injury Prevention
7.0 Spill Response
8.0 Regulated Medical Waste Transportation Requirements
9.0 Definitions
Post-Test
Course Objective
This study program will provide environmental services
professionals and other infectious waste handlers with the
information they need to do their jobs safely. Program
participants will become familiar with the requirements of the
Occupational Safety and Health Administration’s (OSHA’s)
Bloodborne Pathogens and Hazard Communication
Standards, as well as the Department of Transportation
shipping regulations for infectious wastes. Successful
completion of the post-test will demonstrate knowledge in
the following areas:
• Occupational hazards associated with handling infectious
waste, disinfecting contaminated surfaces, and responding to
infectious materials incidents
• Infection control on the job
• Material Safety Data Sheets and hazards associated with
the use of chemical disinfectants
• Selection of proper personal protective equipment
• Housekeeping and spill response procedures
• The American Hospital Association’s infectious waste
reduction initiative sponsored by the EPA
• Requirements for packaging and transporting infectious or
regulated medical waste
Participants who successfully complete the course receive a
Certificate of Training.
Pre-Test
This test is to help the participant know where he/she stands at the
beginning of the course.
1. A hazard is anything that has the potential to cause injury or
harm. Circle one:
True
False
2. An employee with a fever should always come to work. Circle
one:
True
False
Only if the fever < 100 degrees
3. Diarrhea is often a sign of infection.
Circle one:
True
False
4. Infections are caused by tiny organisms called germs.
Circle one:
True
False
5. Can disinfectants be used on surfaces to kill germs?
Circle one:
Yes
No
Sometimes, depends on the germ.
6. Handwashing is the single most important thing one can do
to prevent the spread of infection.
Circle one:
True
False
7. If you get stuck by a needle, all you have to do to prevent
yourself from getting sick is to wash your hands.
Circle one:
True
False
8. The law requires your employer to provide you with
information about the chemical hazards in your workplace.
Circle one:
True
False
9. It doesn’t matter what dumpster you put medical waste in as
long as it is kept in a red bag.
Circle one:
True
False
10. You can’t get sick from a needlestick.
Circle one:
True
False
Occupational Hazards
1.0 Overview of Occupational Hazards
Environmental services professionals at hospitals and other
health care facilities face many hazards in the workplace
every day. Listed below are some of these hazards:
• When they enter patient rooms, they may become
exposed to infectious diseases.
• They risk exposure to bloodborne pathogens from dirty
needles that are occasionally thrown away in the biohazard
and general waste streams.
• They work with chemicals that are often corrosive and
dangerous if not handled properly.
• They are a category of worker at risk of latex allergy from
ongoing latex exposure.
• They may become injured from slips, trips, and falls, or
heavy lifting.
All of the hazards listed above can be controlled by
establishing warning systems, engineering and administrative
controls, and safe work practices,. To ensure hazard control
in the workplace, the Occupational Safety and Health
Administration (OSHA) has established many laws that
employers must comply with to provide a safe working
environment for their employees.
Microorganisms &
Infectious Agents
2.0 Microorganisms & Infectious Agents
Webster’s dictionary defines the word “microorganism” as an
animal or plant of microscopic size. An animal or plant of this
size is too small to be seen by the naked eye and can only be
seen with a special instrument called a microscope. There are
many different kinds of microorganisms. Some of them are
able to make people sick and are often called germs. A
hospital laboratory has many microscopes on hand for
technicians to use so that they can identify the germs that
make people sick. Germs come in many shapes and sizes and
are sometimes called infectious agents. There are six different
types of infectious agents recognized by the Centers for Disease
Control (CDC) and they are listed below:
1. Bacterial agents - examples include Tuberculosis (TB),
Staphylococcus (staph), or Legionella (Legionnaires’ disease)
2. Fungal agents - examples include Aspergillus (mold) and
Tinea (ringworm)
3. Viral agents - examples include Hepatitis B Virus, Hepatitis C
Virus, HIV (AIDS),
4. Parasitic agents - examples include Giardia and
Trichomoniasis
5. Prions - examples include Kuru and Creutzfeldt-Jakob
Disease (CJD or mad cow disease)
6. Rickettsial agents - examples include Rocky Mountain
spotted fever and Lyme Disease
Although only a few examples have been provided for each of
the infectious agents listed above, there are many more that
make people sick.
In order for an infectious agent to make a person sick, it must
first come into contact with that person. This contact is called
an exposure. Following are examples of exposures that can
occur in a health care facility:
EXAMPLE 1
Infectious bacteria would be found in the spit of a patient with
Tuberculosis (TB). If such a patient coughs, the TB bacteria
get into the air with the spit and can infect anyone in the
room who is not wearing a mask (N-95 respirator). Coming
into contact with the TB bacteria is an example of how a
person could be exposed to TB and become sick with
Tuberculosis.
Tuberculosis is a disease that doctors are having a hard time
treating and many people who get this disease die.
Environmental services professionals in the health care
setting must protect themselves by wearing masks when
they enter TB isolation rooms. In a 1995 publication, CDC
researchers reported the results of a study that found the
annual risk of contracting TB was higher for hospital
housekeepers than nurses.
EXAMPLE 2
Infectious virus would be found in the blood of a patient with
Hepatitis B (HBV) liver disease. If a environmental services
professional is stuck by a needle that was used to draw blood
from a patient with HBV liver disease, the environmental
services professional becomes exposed to the Hepatitis B virus.
Hepatitis is a disease that attacks the liver and eventually kills
the patient. Environmental services professionals in the health
care setting must protect themselves from needlestick injuries
by wearing puncture resistant gloves when they handle red
bags or sharps containers. In a 1999 alert published by the
CDC, the government reported that six to thirty percent of
unvaccinated workers can get HBV after a single needlestick
exposure. This means that if 100 environmental services
professionals are each stuck with a needle contaminated with
blood containing Hepatitis B virus, then six to thirty of those
professionals will get sick with Hepatitis. There are two ways
to reduce the rate of HBV transmission from needlestick
injuries and they are:
1) To get a Hepatitis B vaccination, and
2) To report all needlestick injuries to the infection control
nurse and accept post-exposure treatment.
The primary goal of a health care facility cleaning program is
to prevent the spread of infectious agents among patients
and healthcare workers. Environmental services
professionals play an important role in achieving this goal by
protecting themselves in the following ways:
• Wearing puncture resistant gloves while handling any
form of hospital waste to include biohazard bags, infectious
waste containers, and trash bags of any color
• If puncture resistant gloves are worn, wash gloves
between patient rooms to avoid transfer of microorganisms
from one patient to another
• Wear proper personal protective equipment when
cleaning up spills of potentially infectious material
• Use an antibacterial soap to wash gloves immediately
after contact with blood and/or body fluids, soiled linen, or
contaminated equipment
• Immediately report needlestick and other sharps-related
injuries to the infection control staff
• Follow any recommendations made by the infection
control staff after a potential exposure to prevent infection
• Participate in OSHA bloodborne pathogen training
• Follow recommended infection prevention practices to
include receiving the hepatitis B vaccination
• Wash hands immediately after removing gloves
• Wash hands before and after eating, smoking, applying
cosmetics, or preparing food
• Stay home to rest when feverish and sick with a cold, flu,
or other infection
Infectious Waste
3.0 Infectious Waste
The Environmental Protection Agency (EPA) states that
infectious waste can produce an infectious disease. For a waste
to be infectious it must contain enough infectious agent to
make a person sick if exposed to the waste material. The
person must come into contact with the waste material for an
exposure to take place. Infectious waste is classified according
to the following categories:
• Isolation wastes are those made in isolation rooms where
patients with infectious diseases are cared for.
• Cultures and stocks of infectious agents and
associated biologicals are wastes generally made in the
laboratory and may include specimen cultures, discarded
vaccines, culture dishes, and devices used to transfer, inoculate,
and mix cultures.
• Human blood and blood products are wastes that can be
found anywhere in the health care facility but most often they
are found in the laboratory, operating rooms, and labor and
delivery areas - these wastes include blood, serum, plasma, and
other blood products.
• Pathological wastes are wastes generally found in the
pathology labs and autopsy suites - these wastes include
tissues, organs, body parts, and body fluids that are removed
during surgery and autopsy.
• Contaminated sharps are wastes that can be found
anywhere in the health care facility but most often they are
found in areas where patients are treated and the laboratory these wastes include hypodermic needles, syringes, glass
pipettes, broken glass, and scalpel blades.
• Contaminated carcasses, body parts, and bedding
are wastes that can be found in a medical research laboratory
where animals are exposed to infectious microorganisms while
researchers try to find out what causes and cures diseases.
• Miscellaneous wastes are those items that are probably
contaminated with infectious microorganisms - they include
contaminated materials found in the dialysis units, surgery and
autopsy suites, and laboratory areas.
If an item has come in to contact with blood or body fluids, it
is considered contaminated and probably infectious, therefore,
it should be treated as infectious waste. All infectious waste
must be disposed of properly in accordance with a federal law
known as the OSHA Bloodborne Pathogens Standard. Proper
disposal means the following:
• All needles and other contaminated sharps must be placed
in a closable, puncture-resistant, leakproof, red or biohazardlabeled container.
• All other infectious wastes must be placed in closable,
leakproof, red or biohazard-labeled bags or containers.
Biohazard Label
According to Health Care Without Harm, a non-profit
organization, “hospitals produce approximately 2 million tons
of solid waste per year.” Of this amount, ten to fifteen
percent is categorized as infectious and the rest is general
waste made up of paper and paper board, plastics, food
waste, metal, glass, wood and other materials. All of the
solid waste is sent to landfills or incinerators for disposal.
Neither method of disposal is ideal. Landfills threaten our
local drinking water supplies by leaking toxic liquids and
incinerators threaten global air supplies by emitting toxic
contaminants. The problem with incinerators is worse than
the problem with landfills because contaminants from
incinerators travel all over the world and can never be
collected and contained once they are released whereas toxic
liquids leaking from landfills can be collected and treated
locally to remove the harmful properties.
According to the CDC, only one category of infectious waste
needs to be incinerated to protect the public health and that
is pathological wastes. Although pathological wastes make
up only 2% of the hospital solid waste stream, some
hospitals send up to 100% of their solid waste in red bags to
a medical waste incinerator causing unnecessary harm to our
global environment.
If 100% of
hospital solid
waste is disposed
of in red bags…...
Only about 10% of
the waste is actually
infectious ……..
And 2% of the
waste is
pathological,
requiring
incineration.
According to the EPA, medical waste incinerators are the fourth
largest known releasers of mercury to the environment. The
reason for this is that mercury waste is being improperly
disposed of in biohazard bags along with other solid wastes
that are not considered infectious. The mercury waste comes
from patient and laboratory thermometers, blood pressure
devices, dilation and feeding tubes, batteries, and fluorescent
lamps. Mercury cannot be destroyed by incineration. It is
instead released through the incinerator smokestack and then
deposited back to land or sea. It eventually gets into fish and
then people eat the fish. When people eat contaminated fish
they can get mercury poisoning. In people, mercury is toxic.
It causes damage to the brain, kidneys, and lungs. When
pregnant women eat mercury contaminated fish, their babies
are born mentally retarded. Thirty nine states have issued over
1,600 warnings against eating mercury contaminated fish
found in their waterways.
In addition to mercury, medical waste incinerators release
dioxin to the atmosphere. Dioxin is a name used to describe a
class of toxic chemicals that cause cancer, birth defects, and a
number of other conditions in humans. It is formed when IV
bags, tubing, and other PVC plastics are burned in an
incinerator as medical waste. It is released from the
incinerator smokestack and travels great distances where it
enters the food chain much like mercury. According to the
EPA, medical waste incinerators are the second largest source
of dioxin pollution of our environment and food supply.
Because of all of the environmental health problems caused by
medical waste incinerators, the American Hospital Association
and the EPA have reached an agreement to work together to
reduce the amount of waste within the hospital system by half
by the year 2010.
A number of actions can be taken to reduce the amount of
solid waste within the hospital system that is sent in
biohazard bags to medical waste incinerators for disposal.
They are as follows:
• Work with hospital administrators to develop policies that
support biohazard bag reduction efforts.
• Provide information to all hospital staff about the toxic
contaminants created by medical waste incineration.
• Educate staff about different categories of infectious waste
and teach them to place only infectious wastes in biohazard
bag containers.
• Place and maintain biohazard bag containers only in those
areas where infectious wastes are likely to be made.
• Place and maintain special biohazard-labeled containers in
areas where pathological wastes are likely to be made and
teach staff to only place pathological wastes in them.
• Keep pathological wastes separate from the other infectious
wastes.
• Send only pathological wastes to a medical waste
incinerator for disposal.
• Make alternative arrangements to properly treat and
dispose of all other infectious waste (e.g. autoclaves,
microwaves, chemical treatment).
Cleaning for Health
4.0 Cleaning for Health
The goal of a health care facility cleaning program is to
prevent the spread of infectious agents among patients and
healthcare workers and to maintain a healthy indoor
environment. A healthy indoor environment is one that is free
of hazardous pollutants. Cleaning is the process of removing
these pollutants from the environment and disposing of them
properly. There are several types of indoor pollutants that can
make us sick and they are listed below:
• Organic Pollutants - these are chemical compounds.
Examples include: formaldehyde, pesticides, and disinfectants.
• Inorganic Pollutants - these include particles and inorganic
gases. Examples include: asbestos, lead, and carbon
monoxide gas.
• Radiation - pollutants include both ionizing (e.g. radon) and
non-ionizing (e.g. electromagnetic fields) types.
• Complex Mixtures - examples include soot and tobacco,
both of which contain organic and inorganic matter.
• Biological Contaminants - referred to as bio-pollutants.
Examples include bacteria, viruses, algae, fungi, ragweed,
mites.
Biological contaminants are the most hazardous pollutants
found in the indoor healthcare facility environment. They are
living organisms, or come from living organisms, and can be
found under certain environmental conditions:
1. There must be a comfortable home or reservoir in which to
hang out which is just about anyplace, and
2. They need nourishment just like us in the form of food
(organic matter) and water.
Aspergillus is a fungus found in dust and is an example of a
common biological contaminant that lives well in soil, water
and decaying material. In health care facilities, it may be
found in the building ventilation system at air intake and
exhaust ducts in areas where organic matter (dust) and water
are present. Air vents in patient bathrooms make ideal homes
for this deadly organism which can become airborne and infect
patients. Immuno-compromised patients are especially at risk
of infection by this bio-pollutant which causes pneumonia and
kills the patient at least 50% of the time. By keeping air vents
clean and free of dirt and debris, environmental services
professionals control environmental conditions so that this
organism can’t grow or multiply.
Another deadly biological contaminant found in the healthcare
facility is a bacteria named Vancomycin-resistant enterococci.
(VRE). The reason why this bacteria is deadly is because it
cannot easily be killed by antibiotics and many patients die once
they become infected with it. Patients may become infected
with VRE by touching contaminated surfaces such as bedrails,
sinks, faucets, and doorknobs, or coming into contact with
health-care workers who do not wash their hands. If someone
comes into the hospital carrying the VRE bacteria, then
whatever that person touches may become contaminated with
VRE. Deadly VRE can survive for weeks on environmental
surfaces. Every year thousands of patients die after becoming
infected with the VRE bacteria during a hospital stay.
Environmental services professionals play a key role in
controlling the spread of VRE throughout the healthcare facility
by washing hands and wearing gloves properly, and diligently
cleaning and disinfecting all environmental surfaces.
Surfaces with regular hand-contact are called high touch
surfaces. High touch surfaces in patient care areas include
items such as telephones, doorknobs, bedrails, light
switches, faucets, and wall areas around the toilet. These
surfaces must be cleaned and disinfected daily to protect
the patient and reduce the spread of nosocomial diseases
such as VRE.
Nosocomial diseases are illnesses that patients acquire during
their stay in the hospital. Another example of a nosocomial
disease is diarrhea caused by the bacteria, Clostridium difficile.
Patients get this infectious disease by coming into contact with
environmental surfaces contaminated with Clostridium difficile.
Patients’ bathrooms tend to be heavily contaminated areas so
they must be thoroughly cleaned and disinfected by
environmental services professionals to prevent the spread of
this disease.
Clostridium difficile
The primary goal of a health care facility cleaning program is to
prevent the spread of nosocomial disease among patients and
healthcare workers. Environmental services professionals play an
important role in achieving this goal. Daily cleaning reduces the
amount of microorganisms in the patient care environment.
Cleaning is removing all foreign material (e.g., soil, organic
material) from surfaces and it should be done before disinfecting.
The following guidance is provided to improve the general
cleaning and disinfecting process:
• When selecting a disinfectant for use, choose the least toxic
and most effective cleaning product you can find.
• Always clean from least soiled to more soiled areas and from
top to bottom in the patient rooms.
• Always change the disinfecting solution when it appears dirty
(usually after every 3-4 patient rooms).
• Use a clean cloth or mop head each time a bucket of
detergent/disinfectant is emptied and replaced with fresh, clean
solution.
• Dusting reduces potential food for Aspergillus and prevents
infection in hospitalized patients and allergies in employees.
• Dust can be removed without making patients sick by using a
chemically treated cloth/mop or a cloth dampened with approved
disinfectant.
• When dusting, it is important NOT to shake the cloth/mop
because dust and fungal spores will then get in the air. If
patients breathe in these spores, they may get sick and die.
• While dusting ceilings and vents, report any stains and/or wet
areas immediately for repair. Fungus will start to grow on wet
ceiling tiles within 72 hours.
Special care areas (e.g., operating rooms, isolation rooms, and
protective environments for immuno-compromised patients) need
additional attention during the cleaning and disinfecting process.
Consider the following strategies for process improvement:
• Use a bucket method for cleaning each special care area,
where a clean cloth is dipped into a bucket filled with approved
disinfectant and items are cleaned and left wet for ten minutes.
• Daily cleaning should include the washing and disinfecting of
walls around light switches, doorknobs, and other high touch
surfaces.
• Use CLEAN mops and CLEAN mop water for cleaning and
disinfecting the floor in each special care or isolation room.
• When a patient is discharged from a special care area, throw
away all disposable items, change any cubicle curtains, and
disinfect all surfaces including chairs, tables, ledges, call lights,
telephones, sinks, showers, and toilets.
• Avoid the use of cleaning equipment that produces mists.
• If a vacuum is needed to clean the floor in a special care area,
use one with a clean HEPA filter on the exhaust. Keep the door
to the special care area closed when vacuuming.
It can not be emphasized enough. Environmental services
professionals play a key role in preventing the spread of
infectious agents among patients and healthcare workers.
Diligent housekeeping keeps microorganisms and other biopollutants under control and reduces the spread of nosocomial
disease. The environmental services professional must look for
and report to management conditions that may promote the
growth of microorganisms.
Management staff must work cooperatively with environmental
services professionals and maintenance personnel to maintain a
healthy indoor environment. The following basic control
measures are suggested for maintaining healthy indoor
environments at health care facilities:
• Follow a schedule for all cleaning and maintenance activities.
• Remove dirt and debris from all environmental surfaces on a
daily basis and clean and disinfect as appropriate.
• Vacuum carpet regularly and deep clean with an effective
extraction method at least once a month.
• Clean and disinfect air ducts before dirt and dust have a
chance to build up.
• Clean, disinfect, and dry surfaces within 24 hours after a
flood.
• Immediately remove and dispose of materials wet with
sewage-contaminated water. Clean, disinfect, and dry any
contaminated surfaces.
• Do not allow water to accumulate and stagnate anywhere in
the indoor environment.
• Routinely clean all indoor humidifiers with a disinfectant such
as diluted bleach (1:9) or hydrogen peroxide (3%).
• Maintain relative humidity below 60 percent.
• Clean and disinfect bathrooms daily.
• Clean and disinfect cooling towers routinely.
• Clean or replace air filters routinely.
• Have fabrics cleaned professionally every six months (drapery
and upholstery).
Hazardous Material
Safety
5.0 Hazardous Material Safety
Environmental services professionals routinely use chemical
disinfectants to clean surfaces and kill infectious agents in patient
rooms and other areas of the health care facility. If not handled
properly, these chemicals can cause serious injuries such as eye
damage, respiratory problems, chemical burns, or severe skin
irritation. To prevent such injuries, the OSHA Hazard
Communication Standard requires all health care employers to
provide information and training to their employees about the
hazards associated with the chemicals in their workplace.
Specifically, employers must tell their employees about the
requirements of the OSHA Hazard Communication Standard, any
operations in their workplace where hazardous materials are
present, and the location and availability of the health care
facility’s written hazard communication program, including the list
of chemicals in use by the facility and the required Material Safety
Data Sheets (MSDS) provided by the chemical manufacturers.
Employers must also provide training to their employees
on the following topics:
• Ways or how to detect the presence or release of a hazardous
chemical in the workplace;
• The physical and health hazards of the chemicals in the
workplace and the measures that can be taken by environmental
services staff to protect themselves from these hazards, including
safe work practices, emergency procedures, and personal
protective equipment to be used; and
• The facility’s hazard communication labeling system, the
hazard information provided by the MSDS, and how
personnel can obtain and use the hazard information on the
MSDS.
In order to understand the hazard information provided by the
MSDS, environmental services professionals must first learn
something about the nature of chemicals. Chemicals are made
up of single or multiple elements. Oxygen in the air that we
breathe is a chemical made up of a single element - two
molecules of oxygen (02). Water is a chemical made up of two
elements - two molecules of hydrogen and one molecule of
oxygen (H20). The most common chemicals in use are made up
of three elements - carbon, hydrogen, and oxygen. Chemicals
also come in different forms - solids, liquids, gases, or vapors,
and can even be radioactive.
H-3, also known as Tritium, is an
example of a radioactive material
which is made up of three
hydrogen molecules. It is often
used by scientists in biomedical
research laboratories.
Isopropyl alcohol, ethylene oxide, formaldehyde, ether, and
glacial acetic acid are examples of some of the chemicals used
everyday in healthcare facilities.
Chemicals change from one form to another depending on
temperatures and pressures. Water turns to ice when the
temperature drops below 32 degrees F. When water is heated
to the boiling point, it evaporates and turns into a vapor.
Some chemicals evaporate at or below room temperatures
becoming airborne vapors.
Gasoline is a common chemical that becomes an airborne vapor
at and below room temperature. It is very flammable with a
flash point of -45 degrees F. This means that at 45 degrees
below zero, gasoline will give off enough vapor to catch on fire
in the presence of a spark or flame. In addition to being
flammable, gasoline vapors are very dangerous because they
are harmful to human health.
Any chemical can be harmful to human health. How harmful a
chemical is depends on how much of it gets into the body and
how toxic it is. Chemicals can enter the body in one of four
ways:
• They can be inhaled (breathed in);
• They can be ingested (swallowed);
• They can be absorbed through the skin or eyes; or
• They can be injected.
When a chemical enters the body, an exposure has taken place.
A few chemicals are highly toxic and can cause death
immediately or soon after exposure. More commonly, however,
chemicals cause sudden, short term exposure effects such as
burning of the eyes, skin, or lungs or chronic, long term
exposure effects such as cancer or birth defects.
Formaldehyde is an example of a chemical that may cause
both long and short term exposure effects. It is suspected to
cause cancer so it is called a suspected carcinogen. It is also
considered a corrosive. If a material has a pH of less than 3 or
greater than 12, then it is considered corrosive and it could
irritate, burn and/or destroy human skin upon contact. It is
very important to wear Personal Protective Equipment (PPE)
when working with corrosive material.
OSHA has set guidelines for safe levels of exposure to many
airborne contaminants including mists, gases, vapors, dusts,
and fibers. These are known as Permissible Exposure Levels or
PELs. The American Conference of Governmental Industrial
Hygienists (ACGIH) has also set guidelines for safe levels of
exposure to many contaminants. These are known as
Threshold Limit Value-Time Weighted Average (TLV-TWA)
concentration levels or TLVs. If a safe exposure level has been
identified by OSHA or the ACGIH for a particular material, then
it will be provided on the MSDS.
Unsafe levels of exposure may occur in the work place at any
time in the event of a spill or release of a hazardous material. It
is therefore very important that workers know where hazardous
materials are stored or used and how to detect a spill or release
in their work place. Some hazardous materials have warning
properties that alert the worker to a potential exposure in the
event of a release. Examples of warning properties include odor,
headache, burning or tearing eyes, or coughing.
Not all hazardous materials have warning properties and in some
cases the warning properties do not occur until after the
employee has been exposed to a dangerous amount of material.
In such cases, employers may install alarm systems that go off
when levels of exposure are immediately dangerous to life and
health. Ethylene oxide is a toxic gas that is used in many
healthcare facilities to sterilize surgical instruments. It is
considered a carcinogen and a reproductive hazard. Because it
doesn’t take much of it to cause permanent damage or death,
many hospitals have installed alarm systems in and around the
sterilizer areas to alert workers in the event of a release. Some
hospitals have eliminated the use of ethylene oxide altogether.
They have found a less hazardous material to use in their
sterilizers. Using a less hazardous material to do the same job is
known as “substitution.”
If a substitute material cannot be found to do the job, a toxic or
other hazardous material can be used safely in the work place as
long as precautions and procedures are in place to protect the
worker from exposure. Safe work practices or precautions for
using a particular chemical may be found in the MSDS or on the
product label. Below are some common precaution statements
found on product labels:
• Use with adequate ventilation;
• Keep away from sources of ignition (e.g. heat, flame);
• Wear chemical splash goggles;
• Wear rubber gloves to avoid skin contact.
Gloves, coveralls, goggles, face shields, aprons, and respirators
are all examples of Personal Protective Equipment (PPE). If
properly and consistently used by the worker, PPE can provide
excellent protection against chemical hazards. The MSDS will state
what type of PPE the worker needs to wear to prevent exposure
while handling the material. If an exposure does occur, the MSDS
also provides health hazard and emergency first aid information.
To summarize, the OSHA Hazard Communication Standard
requires chemical manufacturers to assess the hazards of the
chemicals they make. For every chemical found to be hazardous,
manufacturers must develop a Material Safety Data Sheet (MSDS)
and provide it to people and organizations that purchase their
products. Employers such as hospital organizations are then
required by the OSHA Hazard Communication Standard to train
their employees on the hazard information provided by the MSDS.
BEAUCOUP is a common chemical used by environmental services
professionals in the health care industry. The manufacturer has
generously provided a MSDS for your review. You will find it at
the end of this chapter. Please take it out of your binder and use
it to answer the following questions:
1. What is the name of the product?_______________________
2. Who makes the product?______________________________
3. What is the product used for?__________________________
4. What hazardous ingredients are in the product? ___________
__________________________________________________
__________________________________________________
5. Has OSHA set a guideline for safe exposure to any of the
ingredients in this product? Yes or No
6. If OSHA has set a guideline for safe exposure to one of the
ingredients in the product, what is the name of the ingredient
and what is the Permissible Exposure Level? ________________
____________________________________________________
____________________________________________________
7.
What does the product look like? ______________________
____________________________________________________
8.
Is the product corrosive? Yes or No
9.
Is the product flammable? Yes or No
10. Is the product reactive? Yes or No
11. What type of PPE should you wear when you use this
product?______________________________________________
_____________________________________________________
12. What do you do if you get this product in your eye? ______
_____________________________________________________
_____________________________________________________
13. What phone number can you call if there is a medical
emergency and you need more information about this product? _
_____________________________________________________
14. What does MSDS mean? ____________________________
_____________________________________________________
ECOLAB
Ecolab Inc.
Ecolab Center
St. Paul, Minnesota 55102
61026143
MATERIAL SAFETY DATA SHEET
Page 1 of 2
MEDICAL EMERGENCIES ONLY (24 Hour Service):
1-800-328-0026
Medical Calls from Outside of the USA:
1-651-222-5352
PROFESSIONAL PRODUCTS
ECOLAB INC.
370 WABASHA STREET NORTH
ST. PAUL MN 55102
Product Information: 1-800-242-5362 Issue Date: July 9, 1999
1.0
IDENTIFICATION
1.1
1.2
1.3
Product Name: BEAUCOUP
Product Type: Phenolic Detergent Disinfectant EPA 303-223
Hazard Rating: Health: 2
Fire: 0
Reactivity:
2.0
HAZARDOUS COMPONENTS
2.1
2.2
2.3
2.4
CAS No.
o-Phenylphenol
90-43-7
o-Benzyl-p-chlorophenol 120-32-1
p-t-Amylphenol
80-46-6
Isopropyl alcohol
67-63-0
(2-propanol, IPA)
%
3
4.5
1.5
2
(mg/m3)
PEL
No
No
No
980
0
TWA
No
No
No
985*
*(ACGIH STEL = 1230)
STEL = ACGIH short term exp. Limit (l5 min.)
PEL = OSHA 8 hr ave in air
TWA = ACGIH 8 hr average
C = ceiling limit in air, do not exceed
3.0
PHYSICAL DATA
3.1
3.2
3.3
3.4
3.5
Appearance: Reddish brown liquid; floral/phenolic odor
Solubility in Water: Mixes with Water in all proportions
pH: 12 - 13 (100%);
9.5 - 10.5 (use solution)
Initial Boiling Point: > 212 deg F
Specific Gravity: 1.05 @ 68 deg F
4.0
FIRE AND EXPLOSION DATA
4.1
4.2
Special Fire Hazards: None
Fire Fighting Methods: Product does not support combustion
5.0
REACTIVITY DATA
5.1
5.2
Stability: Stable under normal conditions of handling.
Product
separates upon freezing; restore by stirring at room temperature.
Conditions to Avoid: Do not mix with anything but water.
6.0
SPILL OR LEAK PROCEDURES /USE PROPER PROTECTIVE EQUIPMENT
6.1
Cleanup: Dike or dam large spills. Pump to containers or soak up on
inert absorbent. Flush residue to sanitary sewer.
6.2
Waste Disposal: Consult state/local authorities for limits on
chemical waste disposal.
Note: Substances Subject to SARA 313 Reporting Are
Indicated by “#”
ECOLAB
Ecolab Inc.
Ecolab Center
St. Paul, Minnesota 55102
929958
MATERIAL SAFETY DATA SHEET
Product: BEAUCOUP
Page 2 of 2
PROFESSIONAL PRODUCTS
ECOLAB INC.
MEDICAL EMERGENCY ONLY, 24 HOUR SERVICE: 1-800-328-0026
7.0
HEALTH HAZARD DATA
7.1
Effects of Overexposure to Concentrate:
Eyes: Causes eye damage, possible chemical burns.
Skin: Causes skin irritation, possible chemical burns.
If Swallowed: Harmful. May damage mucosal tissue. Large doses
may cause circulatory shock, respiratory depression, convulsion.
If Inhaled: Vapor or mist may cause irritation.
8.0
FIRST AID
8.1
Eyes: Flush at once with cool running water. Remove contact lenses
and continue flushing for 15 minutes, holding eyelids apart so as to rinse
entire eye. CALL A PHYSICIAN IMMEDIATELY.
8.2
Skin: Immediately flush skin with plenty of cool running water for
at least 15 minutes. Wash contaminated clothing before reuse.
8.3
If Swallowed: Rinse mouth at once; then drink 1 or 2 large glasses
of water. DO NOT induce vomiting. NEVER give anything by mouth to an
unconscious person.
8.4
If Inhaled: If affected, move to fresh air.
IMMEDIATELY CALL THE MEDICAL EMERGENCY NUMBER, 1-800-328-0026, A POISON
CONTROL CENTER, OR A PHYSICIAN
9.0
PROTECTIVE MEASURES
9.1
FOR CONCENTRATE:
Eyes: Wear chemical splash goggles. For continued or severe
exposure, wear a face shield over the goggles.
Skin: Wear rubber gloves.
USE SOLUTIONS: Avoid contact with use solutions. These may also be
hazardous. Use protective equipment as necessary.
9.2
10.0
ADDITIONAL INFORMATION/PRECAUTIONS
10.1
Purpose of 7/9/1999 issue: System conversion and editorial update.
Replaces May 12, 1998 issue.
KEEP OUT OF REACH OF CHILDREN
The above information is believed to be correct with respect to the formula
used to manufacture the product. As data, standards and regulations
change, and conditions of use and handling are beyond our control, NO
WARRANTY, EXPRESS OR IMPLIED, IS MADE AS TO THE COMPLETENESS OR CONTINUING
ACCURACY OF THIS INFORMATION.
Needlestick and Injury
Prevention
6.0 Needlestick and Injury Prevention
The National Institute of Occupational Safety and Health (NIOSH)
published an alert in November 1999 to provide current scientific
information about the risk of needlestick injury and the
transmission of bloodborne pathogens to health care workers.
According to this alert, it is estimated that 600,000 to 800,000
needlestick and other percutaneous injuries occur annually among
health care workers in the United States. About half of these
injuries go unreported. Data suggests than at an average hospital,
approximately 30 needlestick injuries occur per year for every 100
beds. Of the reported needlestick injuries, approximately 41%
occur for the following reasons:
• Improperly disposed sharp;
• Disposal-related causes;
• Collision with health care worker or sharp; and
• Cleanup.
In an article published in the Journal of Occupational Medicine in
January of 1991, researchers provided data from a study of
housekeepers’ injury experiences in medical laboratories at a major
university. They reported an incidence rate of forty six injuries per
100 housekeepers per year. 37% percent of the injuries were cuts
and punctures and seventy percent of these were attributable to
glass, needles, or cutting instruments. 65% of the housekeepers
surveyed indicated that they did not always report their injuries.
To reduce the risk of needlestick and other injuries, the following
control measures are recommended to protect the environmental
services professional:
• Always wear whatever personal protective equipment is
necessary to do the task safely to protect your skin, work clothes,
and mucous membranes from contact with potentially infectious
materials (e.g. gloves, masks, face shields, gowns, and aprons).
• A gown or apron should be worn if there is a possibility of
contact with infectious materials on your work clothes.
• A mask and goggles or eye protection should be worn if there is
a possibility of contact with infectious materials in your eyes,
nose, or mouth.
• Gloves should be worn to protect your hands from contact with
chemicals and potentially infectious materials.
• Wear puncture resistant gloves when performing high risk tasks
(e.g., changing out needle boxes, cleaning up broken glass,
handling infectious waste containers).
• Locate puncture resistant leak-proof containers for sharps and
needle disposal in areas where they are convenient and likely to
be used by health care providers.
• Ensure that sharps and needle disposal containers are emptied
before they become full.
• Report to management any sharps containers that are mounted
too high or are not easily accessible to health care providers.
• Report to management any needles or other sharp items not
properly disposed of by the health care providers.
• Use a brush and dust pan to pick up broken glass which may be
contaminated with blood or other body fluids.
• Handle contaminated laundry including sheets as little as
possible. Do not shake out these items. Hold them away from
your body and place in the linen hamper without pressing down
on them.
• Carry red bags or other containers of medical waste away from
your body.
• When cleaning up contaminated areas, minimize splashing,
spraying, and spattering.
• Bandage any cuts on your hands before putting on gloves.
• If latex gloves are worn, always wash and remove them after
cleaning a patient’s room or any other potentially contaminated area.
• Dirty gloves should never be worn after the cleaning job is done wearing them around the hospital contaminates surfaces and
spreads disease among the patients.
• Always wash hands after removing gloves and whenever they are
dirty.
• Always wash hands in between patient rooms.
• Follow safe work practices (e.g., do not eat, drink, smoke, apply
lip balm, or handle contact lenses where there might be exposure to
blood or other potentially infectious materials).
• Keep food and drinks away from areas where blood or other
potentially infectious materials are present.
• Report needlestick injuries and other potential bloodborne
pathogen exposures to the infection control staff at your health care
facility.
• Follow any recommendations made by the infection control staff
after a potential exposure.
• Ask the infection control staff at your health care facility about the
free Hepatitis B vaccine that is provided to environmental services
professionals.
Spill Response
7.0 Spill Response
Environmental services professionals routinely respond to calls for
assistance in cleaning up spilled materials on the patient wards
and other areas of the hospital. The spilled materials often
consist of human body fluids such as urine, blood, and feces that
may or may not be infectious. Regardless of whether or not the
material is actually infectious, any human body fluid must be
considered potentially infectious and the environmental services
professional should receive training on the following topics:
• The health care facility emergency response plan for hazardous
materials spills (e.g. notification, personal protective equipment
(PPE), spill response and equipment maintenance procedures,
etc…);
• The different types of micro-organisms potentially found in their
workplace to which they are susceptible (e.g. E. coli, MRSA, VRE)
along with definitions and symptoms of exposure;
• Spill site security and control;
• The measures that environmental services professionals can
take to protect themselves to minimize their risks of exposure
during cleanup operations to include wearing proper PPE;
• Contaminated surface cleaning procedures;
• Disinfectant selection and effective decontamination
procedures;
• Proper disposal procedures for potentially infectious waste
materials;
• Removing PPE, decontamination and/or disposal procedures;
and
• The health care facility exposure control plan for bloodborne
pathogens and employee health and medical surveillance
program.
Do environmental services professionals require special
training to clean up hazardous material spills in the
hospital environment?
OSHA’s Hazardous Waste Operations and Emergency Response
Standard (HAZWOPER) requires that workers be trained to
perform their anticipated job duties without endangering
themselves or others. A hazardous material spill that poses a
significant safety or health hazard to individuals in the
immediate area requires clean up by employees who have
received some degree of HAZWOPER training.
A spill that presents a minor safety or health hazard to
individuals in the immediate area is considered “incidental” and
may be safely cleaned up by employees who have not received
HAZWOPER training. An incidental spill is a release of
hazardous material which does not have the potential to
become an emergency within a short time frame. Incidental
releases are limited in quantity, exposure potential, or toxicity
and present minor safety or health hazards to employees in the
immediate work area or those assigned to clean them up. An
incidental spill may be safely cleaned up by an employee who is
familiar with the hazards of the material.
It is up to management personnel to decide whether or not a
spill is incidental.
The properties of the hazardous material (e.g. toxic, flammable,
corrosive, radioactive, etc…) and the particular circumstances of
the spill itself, such as amount of material, location of spill,
ventilation, etc., will determine whether or not employees can
safely clean up the spill. Additionally, there are factors that may
lessen the hazards associated with the spill and its clean up,
such as the knowledge of the employee in the immediate work
area, the response and personal protective equipment (PPE) at
hand, and the pre-established standard operating procedures for
responding to spills of the hazardous material. In some cases,
there may be some engineering control measures that
employees can activate to assist them in controlling and
stopping the hazardous material release (e.g. turning off a valve,
turning on a fan).
These considerations (properties of the hazardous material, the
circumstances of the spill, and the mitigating factors in the work
area) combine to define the spill as incidental or one that would
require an emergency response. The definition is facility-specific,
a matter of policy, and is a function of the health care facility
emergency response or contingency plan.
Potential spills of hazardous materials in the health care facility
can be defined as follows:
1. Spills that are clearly incidental regardless of the
circumstances,
2. Spills that may be incidental or may require an emergency
response depending on the circumstances, and
3. Spills that clearly require an emergency response regardless
of the circumstances.
Spills that are Clearly Incidental
Example: If a hazardous material in a laboratory is always stored
in very small amounts, such as pint sizes down to test tubes, and
the hazardous material does not pose a significant safety and
health threat if spilled in the immediate vicinity at these amounts,
then the risks of having a release that escalates into an
emergency are minimal. In this example, incidental spills may
occur and employees will be able to clean up the spills safely if
they have been trained in accordance with the Hazard
Communication Standard.
Spills That May Be Incidental or Require an Emergency
Response Depending on the Circumstances
Example: A release of mercury in a plant that manufactures
mercury thermometers may not require an emergency response
because of the advanced knowledge of the personnel in the
immediate vicinity and the equipment available to handle the
release. However, the same size spill inside a patient exam room
may require an emergency response by specially trained
personnel. The health care facility’s emergency response plan in
this case would call for evacuation of all individuals from the
exam room and notification of the spill response team or the
hazardous material contractor.
Spills that Require an Emergency Response
Regardless of the Circumstances
There are spills of hazardous materials that pose a significant
threat to health and safety that, by their very nature, require an
emergency response regardless of the circumstances surrounding
the release or the mitigating factors. An employer must
determine the potential for such an emergency and plan response
procedures accordingly. Response procedures should be provided
in the health care facility’s emergency response plan.
An emergency response includes, but is not limited to, the
following situations:
1. The response comes from outside the health care facility (e.g.
local fire department);
2. The release requires evacuation of all employees in the area;
3. The release poses, or has the potential to pose, conditions that
are immediately dangerous to life and health (IDLH);
4. The release poses a serious threat of fire or explosion;
5. The release requires immediate attention because of imminent
danger;
6. The release may cause high levels of exposure to toxic
substances;
7. There is uncertainty that the employee in the work area can
handle the severity of the hazard with the PPE and equipment
that has been provided and the exposure limit could easily be
exceeded; and
8. The situation is unclear, or data are lacking on important
factors.
Can you think of an example of a spill or release
requiring an emergency response?
Medical Waste
Transportation
8.0 Regulated Medical Waste Management,
Disposal, and Transportation Requirements
There is a great deal of concern about the proper management of
health care facility wastes. Environmental services professionals are
responsible for picking up the waste at each point of generation and
transporting it to the designated place of disposal or storage at the
facility. If certain wastes are mishandled or improperly disposed of,
health care facilities may be subject to fines. Some of the waste
generated in the health care setting could be infectious and transmit
disease if improperly handled or disposed of. It is important that
environmental services professionals receive training on the following
topics:
• The health care facility waste management plan
• The different types of waste streams at the facility for which they
will be responsible
• The definition and/or designation of infectious waste including
where it is likely to be generated and how it is to be segregated from
the other waste streams
• Proper segregation, containment, and labeling of wastes in the
health care facility
• Department of Transportation (DOT) shipping regulations for
infectious and/or regulated medical waste transported off-site for
treatment/incineration; and
• State or local regulations for medical and/or infectious waste
disposal
OSHA regulates infectious waste in the workplace by enforcing
the requirements of the Bloodborne Pathogens Standard. When
environmental services professionals pick up infectious waste at
each point of generation in the healthcare facility (e.g. patient
rooms, operating rooms, pathology labs, etc…) and transport it
to the designated place of treatment or storage at the facility
(e.g. sani-pak, loading dock etc...) they must do so in
accordance with OSHA regulations. This means the waste must
be properly segregated at the time of pick up with needles and
contaminated sharps in a closable, puncture-resistant, leakproof,
red or biohazard-labeled container and all other infectious waste
contained in closable, leakproof, red or biohazard-labeled bags
or containers.
The infectious waste may or may not be treated on-site at the
health care facility prior to shipment off-site for final disposal. If
the waste is treated on-site at the facility so that it no longer
poses the hazard of an infectious substance, then it is no longer
considered infectious and may be transported off-site as general
waste to a solid waste disposal facility (e.g. landfill, transfer
station) regulated by state or local authorities. If the waste is
not treated on-site, then it is considered infectious and a DOT
hazardous material, and it must be transported off-site in
accordance with DOT shipping regulations for hazardous
materials.
DOT regulations require that all infectious substances, including
regulated medical waste, be prepared for shipment off-site by
trained personnel. Specifically, personnel must receive initial and
recurrent training (every two years) that meets the DOT training
requirements in the following three subject areas:
• General awareness/familiarization training to enable
the employee to recognize and identify regulated medical waste
as defined by DOT;
• Function-specific training to familiarize the employee with
the DOT shipping requirements related to the job that he/she
performs; and
• Safety training concerning the specific hazards associated
with regulated medical waste, safe handling of packages
containing regulated medical waste, and the emergency response
procedures and information required by DOT for every regulated
medical waste shipment in the event of an accidental release.
DOT requires that personnel be tested after receiving the training
on the three subject areas.
A record of current training must be kept by the health care
facility for each employee that prepares regulated medical waste
for shipment off-site to a treatment facility. The record shall
include:
• The employee’s name;
• The most recent training completion date;
• A description, copy, or the location of the training materials
used to train the employee;
• The name and address of the person who provided the
training; and
• Certification that the employee was trained and tested.
In accordance with DOT shipping regulations, regulated medical
waste must be shipped in packages that are properly labeled and
marked. Please take a moment to review the DOT brochure
entitled, “Infectious Substances.”
A shipping paper must also be prepared for every regulated
medical waste shipment that leaves the health care facility. A
description of the regulated medical waste shipment must be
included on the shipping paper as well as the name of the health
care facility and an emergency response telephone number.
The description of the waste shipment on the shipping paper
must include the following information:
• The proper shipping name, Regulated Medical
Waste;
• The hazard class, 6.2;
• The identification number, NA 3291; and
• Packing group, II.
The total quantity of the medical waste being shipped off-site for
treatment must also be entered on the shipping paper. Please
see the example on the following page which shows how to fill
out a shipping paper for a load of untreated regulated medical
waste that is being transported from a health care facility.
It is important for environmental services professionals to
understand that untreated regulated medical waste is considered
an infectious substance and a DOT hazardous material. It must
be transported from the health care facility in accordance with
DOT shipping regulations. If untreated regulated medical waste
is improperly disposed of in the general solid waste stream and
transported off-site to a transfer station or landfill, the healthcare
facility will be subject to fines levied by the local government and
the federal DOT.
$25,000.00
Definitions
9.0 Definitions
• Immuno-compromised patients - patients who are unable to
fight off disease-causing germs
• Special care area - a room that needs special cleaning to keep
germs from entering or leaving the area (e.g. operating rooms,
isolation rooms, protective environments for immuno-compromised
patients)
• Germicide - an agent (usually chemical) that destroys
microorganisms (germs)
• Spore - a sleeping or resting germ
• Bactericide - a germicide used to kill bacteria
• Fungicide - a germicide used to kill fungus
• Tuberculocide - a germicide used to kill Tuberculosis (TB)
• Disinfectant - a germicide that kills all microorganisms on
surfaces but does not necessarily kill their spores
• Sterilant - a germicide that kills all microorganisms including
their spores
• Antiseptic - a germicide that kills microorganisms on skin
(e.g.hands, arms, etc..)
• HEPA filter - high efficiency particulate air filter: a filter that
can remove very small particles, > 0.3 microns in size, from the air
with 99.97% efficiency
• Radioactive Material- a substance that gives off radiation
(waves or particles) that may be harmful causing injury, illness, or
death depending on the type and amount of radiation absorbed by
the individual exposed to the material
• Personal Protective Equipment (PPE) - equipment that acts
as a barrier between the worker who wears it and the hazard;
includes protective eyewear, face shields and masks, gloves, boots,
hats, clothing, and respirators.
• Threshold Limit Value-Time Weighted Average (TLVTWA) - airborne concentration of a given substance that nearly all
workers may be repeatedly exposed to day after day without
adverse health effects, according to the American Conference of
Governmental Industrial Hygienists
• Permissible Exposure Level (PEL) - the airborne
concentration of a given substance that nearly all workers may be
repeatedly exposed to day after day without adverse health effects,
according to the Occupational Safety and Health Administration
• pH - a measure of the acidity or alkalinity of a substance,
numerically equal to 7 for neutral substances like water, the higher
the pH (>7), the more alkaline the solution, the lower the pH (<7),
the more acidic the solution
• Percutaneous - passed through the skin
• Red bag - plastic bag red in color used for the disposal of
infectious waste
• Occupational Safety and Health Administration (OSHA)
Definition of Regulated Medical Waste - liquid or semi-liquid
blood or other potentially infectious materials; contaminated items
that would release blood or other potentially infectious materials in
a liquid or semi-liquid state if compressed; items that are caked
with dried blood or other potentially infectious materials and are
capable of releasing these materials during handling; contaminated
sharps; and pathological and microbiological wastes containing
blood or other potentially infectious materials
• Soaked - saturated to the point of dripping
• OSHA Definition of Other Potentially Infectious Materials
- the following body fluids: semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in dental procedures, any body
fluid that is visibly contaminated with blood, and all body fluids in
situations where it is difficult to differentiate between body fluids,
any unfixed tissue or organ from a human, HIV-containing cell or
tissue cultures, organ cultures, HIV or HBV containing culture
medium or other solutions, and blood, organs, or other tissues from
experimental animals infected with HIV or HBV
• District of Columbia Definition of Infectious Waste - any
waste or combination of wastes of a solid, liquid, contained
gaseous, or semisolid form which because of its infectious
characteristic, as established by the Mayor, may: 1) Cause, or
significantly contribute to an increase in mortality or an increase in
serious irreversible, or incapacitating reversible, illness; or 2) pose a
substantial present or potential hazard to human health or the
environment when improperly treated, stored, transported, or
disposed of, or otherwise managed.
• Department Of Transportation (DOT) Definition of
Infectious Substance - a living microorganism, or its toxin, that
causes or may cause disease in humans or animals
• DOT Definition of Regulated Medical Waste - a waste, or
reusable material, that contains an infectious substance and is
generated in the diagnosis, treatment, or research of humans or
animals
• Prion - infectious protein