Resulting from diagnosis, follow-up and treatment activities (whether preventative, curative or palliative) in both human and veterinary medicine, the waste from healthcare activities may present a number of risks including the risk of infection(1). In France the management of infectious risk healthcare waste has been regulated for over 25 years but is currently undergoing a review which may result in declassification of some of this waste.
Defining infectious risk healthcare waste
Article R.1335-1 of the French Public Health Code considers infectious risk healthcare waste to be waste that “either presents risk of infection due to the fact that it contains viable micro-organisms or their toxins, where it is known, or there is good reason to believe due to its nature, quantity or metabolism, that it will cause illness in human or other living organisms, or that, even in the absence of risk of infection, it belongs to one of the following categories: Piercing or cutting items and products intended to be discarded whether or not they have been in contact with a biological product; partially-used or expired blood products for therapeutic use; human anatomical waste deriving from human body parts that are not readily identifiable ”(2).
Sources of infectious risk healthcare waste
Infectious risk healthcare waste is produced by healthcare establishments (hospitals, laboratories, research centres, blood collection services etc.), professionals in private practice (or “independent practitioners”)(3) and patients who are self-administering. All those producing or storing infectious medical waste are responsible for it; they are required to manage or arrange its management through to its final disposal or recovery.
A specific disposal stream
Since they carry biological agents (viable micro-organisms – bacteria, viruses, moulds, yeasts – or their toxins) infectious risk healthcare waste is handled in such a way as to prevent dangerous exposure and avoid the spreading of infectious diseases, potential exposure through contact with (or projection of) biological liquids, or by piercing or cutting (syringes, needles, scalpels etc.) – often called “sharps” in English-speaking countries.
In France, their management is controlled by detailed regulations specifying packaging, storage, transport, traceability and the training and education of personnel (see the Decrees of September 1999, subsequently modified). Producers are required to place infectious risk healthcare waste (called DASRI in France) into specific approved packaging (boxes, bags, crates) and to store it in a dedicated location that is ventilated and unheated. If they produce less than 15kg/month they can deposit the waste into automated collectors provided at certain waste disposal centres, by presenting a personal electronic key. Above 15kg/month, they are required to organise collection and transport by professionals, with the frequency of collection depending on the amount of waste generated. In addition to the requirements for sorting, packaging and storage, packages leaving the producing establishment have to meet the requirements of the regulations for transport of hazardous materials by road.
While most infectious risk healthcare waste goes for incineration (see Figures box), some require pretreatment by thermal or chemical disinfection followed by crushing (if solid waste), or different methods of treatment for liquid waste, depending on its type (biological, chemical or radioactive). Equipment for pretreatment by disinfection (e.g.: Ecostéryl, Ecodas, Sterilwave etc) must possess conformity accreditation from a body approved by the French Ministry for Health and Access to Care. Once pretreated in accredited equipment, the infectious risk healthcare waste can go to household waste treatment plants.
Household infectious risk healthcare waste
Every year, in France, almost 2 million people use sharps at home as part of their medical treatment. The EPR SAM infectious risk healthcare waste stream instituted by Decree in June 2011 allows self-administering and self-testing patients to go to their pharmacy to pick up a mini-collector for sharps waste (yellow box). Since 2023 they are also able to send back a violet box, intended for infectious risk healthcare waste containing electronics, such as patch pumps, sensors etc. Pharmacies collect these boxes free of charge as per article 89 of France’s AGEC law (in English, the Anti-Waste Law for a Circular Economy) of 10 February 2020.
Since 2012 the EPR SAM infectious risk healthcare waste stream has been operated by DASTRI, the only eco-organisation accredited to date. As at the end of 2023, 95% of pharmacies have joined the DASTRI network, so providing some 20,500 collection points. More recently, with the expansion of in-pharmacy vaccination, a DASTRI system for professionals has been put in place with the Fédération des Syndicats Pharmaceutiques de France (FSPF – Federation of Pharmaceutical Unions) based on the same principle of taking charge of infectious risk healthcare waste from self-administering patients.
Key figures (source: DASTRI, 2023)
The infectious risk healthcare waste industry in France comprises 47 treatment plants for non-electronic potentially infectious medical waste of which 25 units provide treatment by incineration with energy recovery, 15 are disinfection pretreatment sites, 1 UIOM* site with incineration following pre-treatment, and 6 sites for ISDND* storage following pre-treatment. For infectious risk healthcare waste with electronic components, DASTRI offers one separation unit (5 materials: cardboard, metals, plastics, batteries and circuit boards) as part of DASTRI Lab, located near Besançon.
In 2023 DASTRI processed 1,965 tonnes, 820 of which were containers and waste resulting from vaccination. Of these 1,965 tonnes, 1,204 (61.2%) were sent for incineration and 761 (38.8%) had been pretreated, of which 539 tonnes had then been incinerated and 222 tonnes buried at ISDND sites. Further, 4.1 million yellow boxes and over 133,000 violet boxes had been distributed.
*UIOM: Unité d’incinération des ordures ménagères (Incineration unit for domestic waste) – ISDND: Installation de stockage de déchets non dangereux (Non-hazardous waste storage facility)
Calls for infectious risk healthcare waste to be declassified into ordinary waste
The High Council on Public Health (HCSP, Haut Conseil de la Santé Publique) revisited the definition of infectious risk healthcare waste in June 2023. For the Council, “waste with an infection risk (biological risks) means a waste from healthcare activities derived from an active breeding ground for biological pathogenic agents – groups 2 to 4 (an infection site or microbial colony). Waste with an infection risk could also be waste from healthcare activities which is heavily impregnated with blood, secretions or excretions and poses a risk of leakage.”
The HCSP excludes from infectious risk healthcare waste “healthcare waste not from an active breeding ground for pathogenic biological agents; healthcare waste resulting from a patient exhibiting infection, except where they have been in contact with an infection site; healthcare waste that has lost its infection risk properties through treatment or disinfection; recognisable single-use medical devices that have not been in contact with an infection site or microbial colony or which have not been impregnated with large amounts of blood, secretions or excretions.”
Some concrete examples
According to the HCSP, a tongue depressor used for one patient showing no signs of infection, an individual face mask used by a healthcare professional, a dressing applied following subcutaneous injection, and an operating sheet stained with a few drops of blood are considered as healthcare waste that can be handled as household waste.
By contrast a tongue depressor used for a patient exhibiting a rhinopharyneal infection, an anti-projection mask worn by a patient suffering a pulmonary infection, a dressing for a patient exhibiting a cutaneous infection or a operating sheet heavily impregnated with blood are considered as infectious risk healthcare waste.
At a time of simplification, this new approach may be challenging. For example, the question arises of who, within the establishment, will determine which or other waste has been in contact with an infection site? In the same way, where should the line be drawn to determine the amount of blood, secretions or excretions impregnating a piece of waste?
In October 2024 the HCSP provided some initial answers in its advice relating to revision of the Guide national sur l’élimination des DASRI (National Guide for the Disposal of Infectious Risk Healthcare Waste) published in 2009. Beyond using its new definition of infectious risk healthcare waste it has recommended the “training of healthcare staff, in urban locations and in healthcare and medico-social establishments, to be able to properly identify infectious risk healthcare waste that can be treated as domestic waste depending on the context and clinical condition of the patient, and equally taking into account the risk of infection, proven or suspected, in the patient and the biological risk to healthcare professionals for the collection and handling of waste.” It also suggests “implementing suitable training for those involved in the logistics and collection of waste in the new recycling and recovery sectors”. It also recommends “ensuring that, in accordance with the regulations, as many people as possible are involved in combating waste and supporting a circular economy (the AGEC law), for the specific recycling and recovery sectors for waste from other economic activities and potentially infectious waste from healthcare activities, chemical/toxic, radioactive or resulting from medicinal products. Actions focus on the sorting and any preparation of the waste, containers, storage, transport and treatment, in order to avoid clogging-up the household waste disposal stream.
Waste professionals respond
Faced with this, some players in the Waste industry are sounding the alarm. For the FNADE and the SNEFID(4) “this sorting, which relies on the caregivers to identify waste according to these criteria, is a source of sorting errors, whereas today healthcare establishments sort their waste into ‘potentially contaminated (risk) waste’ and “non-hazardous waste” (that can be added to household waste), i.e. sorting that is simple to perform and ensures the safety of the whole sector.”
The two organisations stress that “the precautionary principle must be systematically applied through a clear rule that is directly applicable, without requiring personal judgement, systematically classifying as infectious risk healthcare waste, all waste in contact with the human body – in other words all unpackaged healthcare waste.” For them, in addition to waste that must be subject to sorting at source upstream of healthcare provision, “handling of other waste should be prioritised in energy recovery plants to avoid any contact between people and waste.”
One thing’s for sure, we haven’t heard the last of this.
1) Other risks considered as chemical and toxic, radioactive risks and mechanical risks.
2) Also similar to infectious risk healthcare waste is waste resulting from training, research and industrial production in the human and veterinary medicine sectors, as well as that resulting from embalming, cosmetic surgery, dermal penetration tattooing, and clinical or non-clinical trials conducted on cosmetic and tattoo products.
3) Difficult to establish, infectious risk healthcare waste generated by healthcare professionals in private practice is estimated at between 9,000 and 13,000 tonnes (Ademe).
4) FNADE: French Federation of Waste Management and Environmental Service – SNEFID: French National Federation of Waste Management Companies
