Report 3 of the Council on Scientific Affairs (A-02)
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At the 2001 American Medical Association (AMA) Annual Meeting, the House of Delegates adopted the recommendations of Council on Scientific Affairs (CSA) Report 2 (A-01), "Safe Disposal of Syringes, Needles, and Other Sharps in the Community,"¹ which was based on the fact-finding meeting "Safe Community Syringe Disposal: Understanding the Barriers and Creating Solutions." This meeting, which brought together more than 30 individuals representing the major stakeholders, was held at the headquarters of the American Pharmaceutical Association (APhA) in Washington, DC, on January 29-30, 2001.

CSA Report 2 (A-01) identified and discussed the public health implications of improper sharps disposal in the community and summarized extant efforts to promote the safe disposal of used sharps in the community. The report concluded that the improper disposal of used sharps is an important public health problem. Populations exposed to the hazards posed by improperly disposed sharps in the community include children, sanitation workers, waste management employees, hospitality services employees, and others. However, there are no federal regulations or laws that guide the disposal of sharps in the community. While states may have their own system for handling the community disposal of used sharps, many are not successful and guidelines that do exist are conflicting and often inappropriate. This has led to confusion among stakeholders regarding the proper disposal of used sharps in the community.

Thus, the problem is complex, requiring multi-layered solutions focused at local levels. Barriers are many, including issues of cost, confidentiality, convenience, lack of leadership, bias, the federal ban on funding of syringe-exchange programs, and lack of public awareness. Definitive data are lacking on several issues surrounding community sharps disposal, such as the incidence of injuries sustained by workers in the community (eg, hospitality staff, sanitation workers), the current guidelines and regulations at the state and local level, and the proper disposal of used sharps in the community (eg, in the municipal waste stream, or reclassified as special waste). There also remains a critical need for an appropriate safe disposal guideline for self-injectors who continue to deposit used sharps in the municipal waste system.

CSA Report 2 (A-01) recommended that the AMA recognize that used sharps in the community pose a public health hazard in diverse ways to workers and to the public. It called on the AMA to support government action at the national, state, and local levels in collaboration with the solid waste industry, sharps and pharmaceutical manufacturers, pharmaceutical distributors, and appropriate health care organizations, including local, state, and medical specialty societies, to identify, develop, implement, and evaluate strategies to ensure safe sharps disposal in the community. It was suggested that a problem-identification statement be developed that could be released to the local and state level stakeholders, news media, and the public to increase awareness of the problem. A loose coalition of interested stakeholders was established to address this public health problem, and the report recommended that the AMA remain involved in its activities. Finally, following debate at the House of Delegates, an additional recommendation was added, requesting a report back to the House at the 2002 Annual Meeting.

This current CSA report provides an update on AMA activity in this arena since the adoption of CSA Report 2 (A-01).

Data Sources 

Information for this report was derived primarily from various conference calls held monthly among primary stakeholders identified in CSA Report 2 (A-01), and from two organizational meetings held on February 22 and April 2, 2002, in Washington, DC.

AMA Activiites on Safe Community Needle and Syringe Disposal Since Adoption of CSA Report 2 (A-01) 

AMA activity to promote the safe community disposal of used needles and syringes has focused on two major efforts. The first is to develop and disseminate a problem-identification statement to local- and state-level stakeholders, news media, and the public. The second is participation in an advisory group with the goal of establishing a coalition that would continue the efforts initiated by the stakeholders present at the January 2001 meeting in Washington, DC. In addition, as part of the AMA’s efforts to promote awareness of this important public health problem, the CSA presented an abstract based on CSA Report 2 (A-01) at the 2001 National HIV Prevention Conference, held in Atlanta, GA, in August 2001 (Appendix A).² 

Creation of the Problem-Identification Statement. Six participants from the January 2001 fact-finding meeting formed a working group to develop and facilitate eventual dissemination of a problem-identification statement. The purpose of this statement is to increase awareness of the problem; thus, it is to be released to the news media, the public, and to local and state policy officials and stakeholders. The six participants are representatives of the American Diabetes Association (ADA), the AMA, the American Association of Diabetes Educators (AADE), the APhA, the Association of State and Territorial Health Officials (ASTHO), and the Centers for Disease Control and Prevention (CDC). A few months into the process, these six organizations were joined by the National Association of State and Territorial AIDS Directors (NASTAD).

Over the course of several months, representatives from these seven organizations communicated regularly via conference call (at least once a month) and email. A final draft of the problem-identification statement is now ready to go into production (Appendix B). After it is printed, the seven participating organizations will disseminate it to their state and local chapters. A list of names and contact information for local officials of the seven organizations within the state or region will be distributed with the statement. This list will be useful in opening communication channels. An accompanying cover letter will briefly explain and highlight the problem of safe community disposal of used needles and syringes, and will urge local and state officials from the seven organizations to meet with each other and develop an action plan to address the issue in their individual communities.

Supporting Materials for the Problem-Identification Statement. As work progressed on the problem-identification statement, the working group concluded that it would not be appropriate to issue a call to action without providing materials to support the efforts of the state and local representatives who respond. Therefore, the working group is devoting significant effort to developing the following support materials:

1. Guidelines for successful coalition-building;
2. A list of frequently asked questions with appropriate answers for health care professionals regarding community needle and syringe disposal;
3. A discussion paper on the potential impact of the Occupational Safety and Health Administration’s Bloodborne Pathogens Standard on community safe needle and syringe disposal programs;
4. A list of programs already in existence, with the appropriate contact information;
5. A list of Web sites and listservs that detail and discuss community safe needle and syringe disposal programs;
6. Fifty state-level guides describing and discussing all state legislation and regulations that may affect the implementation of a community safe needle and syringe disposal program;
7. A list of state and regional chapters/associations of the seven organizations working on the problem-identification statement; and
8. A list of peer-reviewed references on safe community needle and syringe disposal.

The working group expects that upon the release of the problem-identification statement, these resources will be complete and available for any party that may respond to the call to action. Where possible, these resources will be organized by state and by locality to facilitate action at those levels.

Establishment of a Nonprofit Coalition for Safe Community Needle and Syringe Disposal. One of the recommendations from the January 2001 fact-finding meeting was that a coalition be established that would not only continue the efforts started at the meeting, but would assume a leadership role in promoting the safe community disposal of used needles and syringes. Most participants in the fact-finding meeting recognized that in the absence of a full-time effort, reform in the methods by which needles and syringes were disposed of in the community would not occur; this became the primary motivation for establishment of the coalition. However, it was also recognized that without start-up funding, it would difficult for such a coalition to succeed.

Consequently, concurrent with crafting of the problem-identification statement, the AMA is also working with representatives from APhA, ADA, AADE, ASTHO, CDC, and NASTAD to establish an official not-for-profit coalition that would continue efforts to promote safe community needle and syringe disposal. Representatives from industry (Becton, Dickinson and Company; Waste Management; and Sharps Compliance, Inc) also participated in the establishment of this coalition. At the top of the list of items needing action was funding.

After significant efforts from the industry representatives, start-up funding for this coalition was obtained from Waste Management and Becton, Dickinson and Company to the total amount of $500,000. An important factor in the decision by industry to provide this significant contribution was the commitment shown to this important public health problem by the AMA, the CDC, and the other national associations. Additionally, both companies acknowledge the benefit to their employees and to overall public health should safe community syringe disposal programs be successful on a larger scale.

On February 22 and April 2, 2002, representatives from the stakeholders involved in establishing this not-for-profit coalition met in Washington, DC, along with a facilitator from the Academy for Educational Development, to work out the details necessary to make the coalition official. The meetings were titled "Coalition for Safe Community Needle & Other Sharps Disposal: Setting the Vision & Building the Structure." Appendix C lists the participants. These individuals comprise a temporary advisory body to the coalition.

During the course of the two meetings, the advisory group reached several conclusions and action items. First, the coalition is called the "Coalition for Safe Community Needle Disposal" and its mission statement reads as follows:

The Coalition for Safe Community Needle Disposal is dedicated to the safe disposal of syringes and needles used by individuals in their homes and communities.

Every year, more than 2 billion needles and syringes are used outside of healthcare settings. Improperly disposed needles and syringes are a hazard to workers and the public.

The coalition is a collaboration of businesses, community groups, and government that promotes public awareness and solutions for safe disposal of needles and syringes in the community.

All legal documentation for the incorporation of this coalition as a not-for-profit 501 c(3) corporation has been filed in Texas where it is anticipated that the coalition will be located. Bylaws have been completed and are in the process of being filed. As part of the bylaws, the following organizational structure has been proposed:

There will be one Board of Directors that will manage the coalition in a fiduciary capacity. However, so as to establish some distance in the relationship between the multitude of nonprofit and some government-entitled organizations and the funding/fiduciary activities of the group, a Policy Council will make all program-related decisions. It was recognized that potential difficulties exist in creating these two entities, with the Policy Council ultimately dependent on the Board of Directors for funding to accomplish programs. However, it was felt that this was an appropriate start to the organizational structure and that as the coalition matures, this organizational structure can and should evolve to meet the coalition’s mission.

Board of Directors – Structure and Responsibilities 

1. Members elected by a two-thirds majority vote of the Board to staggered three-year terms;
2. Maintains all fiduciary responsibilities for the coalition;
3. Directs fundraising;
4. Employment of Executive Director;
5. Conducts business/legal aspects of the coalition;
6. Handles employee compensation;
7. No program or policy responsibilities;
8. Five members (with one representative each from Waste Management; Becton, Dickinson and Company; and Sharps Compliance, Inc.). Two (potentially 3) rotating members nominated from the Policy Council;
9. Can form subcommittees when necessary to address a specific business issue;
10. Ultimately responsible for vendor relationships;
11. Officially appoints the members of the Policy Council; and
12. Approves a budget that is developed by the Executive Director with recommendations from the Policy Council.

Policy Council – Structure and Responsibilities 

1. Responsible for establishing direction of coalition activities, in conjunction with the Executive Director;
2. Manages implementation of programs by the Executive Director, staff and committees;
3. Establishes criteria for Policy Council members (it is anticipated that there will be an odd number of members [11] that includes at least one representative from the establishing national associations/organizations, government, business, and consumers);
4. There should be a simple structure with a chair and a secretary;
5. Establishes subcommittees to address specific programmatic issues.

The Board of Directors has already been established with the three members from industry. The remaining two members of the Board will be determined following the establishment of the Policy Council.

The Board of Directors will evaluate potential members for the Policy Council following a coalition-introduction meeting on June 4, 2002, in Washington, DC. The Board will invite all participants of the January 2001 fact-finding meeting, plus any additional stakeholders (eg, pharmaceutical companies), to this June meeting. The meeting objectives include introducing the coalition, orienting stakeholders to the structure and governance of the coalition, and providing information on the coalition’s mission and the materials already accumulated to support its initial work (eg, the problem-identification statement). At the June 4 meeting, the criteria for membership in the coalition will be described and interested stakeholders will be invited to join. To encourage maximal participation, the criteria for membership at this time remains simple: any person or entity (whether corporation, partnership, sole proprietorship, firm or organization, or a department or subdivision thereof (1) whose interest or objective is in helping safeguard the public health against the hazards posed by improper disposal of used sharps; (2) who has made or in the future will make contributions (monetary or nonmonetary) to the coalition; and (3) who meets such other criteria for admissions as shall be established by the Board of Directors from time to time. The Policy Council will then be completed from coalition members. It is expected that the AMA will be represented on the Policy Council, with possible rotation onto the Board of Directors. The AMA is also actively involved in the organization of this June 4 meeting.

In the meantime, the Board of Directors, with advice and approval from the advisory group, has hired a firm, Sommers and Associates, to handle all daily aspects of the coalition, such as communications and public relations. In the long run, this structure represents a cost savings, with increased business flexibility and capacity over the traditional "brick-and-mortar office." An operating budget has been constructed. While start-up funding is at $500,000, Sommers and Associates anticipates that the proper introduction and establishment of the coalition, plus management of responses to the problem-identification statement, will require a first-year budget of $600,000. However, Sommers and Associates has committed its services for the start-up amount in anticipation of its ability to raise money for the second-year budget. It will then recoup the deficit from the second-year budget.

Council on Scientific Affairs Presentation at the 2001 National HIV Prevention Conference

To increase awareness of the issue of safe community disposal of used needles and syringes, the CSA presented an abstract titled "Safe Disposal of Used Syringes, Needles, and Other Sharps in the Community" (Appendix A) at the 2001 National HIV Conference held in August 2001 in Atlanta. This abstract was very well received and more than 400 copies were distributed during its presentation.

Upcoming Steps

 Once the Policy Council for the Coalition for Safe Community Needle Disposal is established, a press release will be issued announcing the coalition and its mission. All materials being prepared in support of the problem-identification statement should be completed at this time. The problem-identification statement will be released the week of June 10 (one week following introduction of the coalition), possibly in conjunction with a major press conference. This opportunity--to have two separate press events (one to announce the coalition and the other to release the statement)--will enhance public and policy-makers’ awareness of this important public health problem. At this point, the advisory group that has driven the formation of the coalition will dissolve and its interests and knowledge of the subject will be represented via participation on the Policy Council.

RECOMMENDATIONS

 The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA directives at the 2002 AMA Annual Meeting:

1. The AMA will continue to implement the recommendations of Council on Scientific Affairs Report 2 (A-01). 
2. The AMA supports the mission of the newly established Coalition for Safe Community Needle Disposal. The mission statement is:

   The Coalition for Safe Community Needle Disposal is dedicated to the safe disposal of syringes and needles used by individuals in their homes and communities.

   Every year, more than 2 billion needles and syringes are used outside of healthcare settings. Improperly disposed needles and syringes are a hazard to workers and the public.

   The coalition is a collaboration of businesses, community groups, and government that promotes public awareness and solutions for safe disposal of needles and syringes in the community.

3. The AMA supports the activities of the newly established Coalition for Safe Community Needle Disposal, which include producing the following materials:

1. Guidelines for successful coalition building;
2. A list of frequently asked questions with appropriate answers for health care professionals regarding community needle and syringe disposal;
3. A discussion paper on the potential impact of the Occupational Safety and Health Administration’s Bloodborne Pathogens Standard on community safe needle and syringe disposal programs;
4. A list of programs already in existence, with the appropriate contact information;
5. A list of Web sites and listservs that detail and discuss community safe needle and syringe disposal programs;
6. Fifty state-level guides describing and discussing all state legislation and regulations that may affect the implementation of a community safe needle and syringe disposal program;
7. A list of state and regional chapters/associations of the seven organizations working on the problem-identification statement; and
8. A list of peer-reviewed references on safe community needle and syringe disposal.

References

1. Report of the Council on Scientific Affairs: Safe Community Syringe Disposal: Understanding the Barriers and Creating Solutions. Available at: http://www.ama-assn.org/ama/pub/category/13586.html. Accessed: 3-1-2002.
2. Tan L, Hawk JC, III, Sterling ML, Turner PL. Safe Disposal of Used Syringes, Needles, and Other Sharps in the Community. Program and Abstract Book, 2001 National HIV Prevention Conference 2001. (Abstract)

AUTHORS: Tan, L; Hawk, JC, III; Sterling, ML; Turner, PL (for the Council on Scientific Affairs, American Medical Association, Chicago, IL)

 ISSUE: To identify and discuss the public health implications of improper disposal of syringes, needles, and other sharps in the community.

SETTING: "Community" is defined as "outside of health care facilities."

PROJECT: To examine the public and occupational health hazards of used sharps outside of health care settings and to identify exemplary programs and appropriate procedures to provide guidance on reducing the incidence of needlesticks caused by sharps that are improperly disposed of in the community, the American Medical Association (AMA) in collaboration with the Centers for Disease Control and Prevention, the American Association of Diabetes Educators, the American Pharmaceutical Association, and the Academy for Educational Development held a fact-finding meeting titled "Safe Community Syringe Disposal: Understanding the Barriers and Creating Solutions." This meeting, which brought together more than 30 individuals representing the major stakeholders, was held in Washington, DC, on January 29-30, 2001.

RESULTS: The improper disposal of used sharps in the community is an important public health hazard. Populations exposed to the hazards posed by such sharps include sanitation workers, waste management employees, hospitality services providers (e.g., hotel maids, janitorial staff), children, and others. These hazards include needlestick injuries, the financial and psychological impact of post-exposure counseling and prevention therapy, and the risk of bloodborne pathogen transmission. However, there are no defined regulations or laws that guide the disposal of home-generated sharps in the community. While states may have their own system for handling the community disposal of used sharps, many are not successful and guidelines that do exist are often conflicting, leading to confusion among stakeholders regarding proper disposal.

LESSONS LEARNED: Meeting participants agreed that the problem of safe disposal of used sharps in the community is complex, requiring multi-layered solutions focused at local levels. Barriers are many, including issues of cost, confidentiality, convenience, lack of public awareness, lack of leadership, bias, drug paraphernalia laws, and the federal ban on funding of syringe-exchange programs. Definitive data are lacking on several issues surrounding community sharps disposal, such as the incidence of occupational injuries in the community (hospitality staff, solid waste workers, etc), the current guidelines and regulations at the state and local level, and the proper disposal of used sharps in the community (e.g., in the solid waste stream, or reclassified as special waste). There is a critical need for appropriate safe disposal guidelines for self-injectors who currently deposit used sharps in the trash. A problem-identification statement concerning the improper disposal of used sharps in the community is being developed that can be used to increase public awareness. A coalition has been established to begin to address this public health problem.

Dear Colleague:

We are asking for your help to improve the options in the community outside of health care settings for safe disposal of used syringes and other sharps. Safe disposal will protect workers and the public from injury and possible disease transmission.

At least 3 billion injections are administered yearly outside of health care settings. About 2 billion of these injections are attributed to the rapidly increasing numbers of people with diabetes and of patients receiving health care at home. About 1 billion injections of illicit drugs a year are made by injection drug users (IDUs). Together, these "self-injectors" generate billions of used syringes a year, many of which are placed in household trash and community solid waste or discarded unsafely, thereby putting workers and the public at risk of needle stick injuries.

A surprise encounter with a used syringe, needle, or other sharp in a playground, park, or at work can provoke intense fears of injury and life-threatening infections with blood borne pathogens (such as, human immunodeficiency virus [HIV] and viral hepatitis [types B and C]). If a needle stick injury occurs, the costs of providing post-injury counseling and prevention measures are significant. To prevent such injuries outside of health care facilities the current systems for disposal of used syringes and other sharps need to be improved.

Worker exposure to used syringes and other sharps placed in community solid waste is increasing. This is due, in part, to changes in the management of community solid waste to reduce the volume of solid waste going to landfills by greater use of manual sorting to remove recyclables. Other workers, such as hotel, office, and "institutional" cleaning staff and janitors, are exposed, in increasing numbers, to used sharps improperly disposed of in the community. While there are limited data on these occupational and non-occupational risks, potential problems that can arise from improperly discarded used sharps include needlestick injuries and potentially fatal blood borne infections.

Unfortunately, the options for safe disposal in the community of used syringes and needles are often limited and poorly understood. Laws and regulations governing medical waste (including syringes and other sharps) were primarily designed for health care facilities and medical waste operations. These laws and regulations can hinder community efforts to gather and consolidate household syringes and other sharps for safe disposal as medical waste (e.g., at fire stations or pharmacies).

Most self-injectors have received limited and at times contradictory advice about safe disposal of used sharps in the community. Physicians, pharmacists, and diabetes educators, to whom they would most likely turn for help, are uncertain of what to advise.

For IDUs, the criminal penalties for syringe possession are strong disincentives to safe disposal of potentially infectious used syringes and needles. Many IDUs are unwilling to participate in safe disposal by accumulating used syringes and carrying them to disposal sites because of the real risk of arrest for possession of drug paraphernalia.

Dramatic reduction (and ideally complete elimination) of used syringes and other sharps from community solid waste would be the most effective approach to protect solid waste industry workers. Practical solutions are needed to eliminate used syringes and needles from the community solid waste. While these solutions are being developed, there is a critical need for safe disposal guidelines for self-injectors who continue to deposit used sharps in solid waste.

To help address this public health problem, a meeting titled Safe Community Syringe Disposal: Understanding the Barriers and Creating Solutions was held in Washington, DC in January 2001. This meeting brought together key representatives from professional associations, industry, government, and public health.

Based upon data presented and discussions at that meeting, the participants support the following statement regarding the safe disposal of used syringes, needles, and other sharps in the community:

Improperly disposed used sharps in the community pose a public health hazard in many ways to both workers and the public. While this complex problem requires national leadership, successful solutions must be focussed at the state, local and community levels. Collaborative efforts involving national, state, and local governments, the solid waste industry, labor organizations, syringe and pharmaceutical manufacturers, pharmacies and pharmaceutical distributors, and health associations are needed to identify, develop, and implement strategies to ensure safe disposal of used sharps in the community. Ideally, these strategies should reduce or eliminate sharps in solid waste; should be low-cost and convenient for the public, and easily implemented in the community.

The following national organizations have issued policy statements on disposal of used syringes and other sharps:

AADE (2001) . . . sharps that are disposed of may expose waste industry workers and the general public to injury or infection. Safe disposal of sharps is an issue of concern for diabetes educators. Whether in clinical settings, shopping malls, other public areas, or in the home, it is critical that safe practices be carried out consistently and thoroughly.

ADA (2002) The American Diabetes Association (ADA) supports developing strategies for the safe disposal of needles, syringes and other sharps in the community.

AMA (2000) The American Medical Association (AMA) recognizes that used sharps in the community pose a public health hazard in diverse ways to workers and to the public.

APhA (2001) APhA supports collaboration with other interested health care organizations, public health and environmental health groups, waste management groups, syringe manufacturers, health insurers and patient advocacy groups to develop and promote safer systems and procedures for the disposal of used needles and syringes by patients outside of healthcare facilities.

ASTHO (2002) Safe disposal of used and potentially contaminated needles, syringes and sharps is a public health concern. Accidental needle sticks from an improperly discarded syringe or sharp can possibly infect someone and should be considered hazardous waste. Given the continuing unsafe disposal of syringes and the likely increase in the use of syringes outside health care settings, ASTHO recommends that communities consider organizing programs for safe disposal of syringes that are tailored to their local situations.

Our associations encourage organizations and state leaders in these fields to convene state and local governments, the solid waste industry, syringe and pharmaceutical manufacturers, pharmacies and pharmaceutical distributors, health associations, and other interested parties to review and improve the current options for safe disposal of used sharps generated in the community by patients and IDUs. These reviews could include:

• estimating the incidence, outside of health care facilities, of needle stick injuries to workers and the public;
• determining the current practices, outside of health care settings, for disposal of used syringes and other sharps generated by patients and IDUs;
• describing existing community sharps disposal programs and their potential for expansion and/or modification;
• examining local and state regulations and legislation to determine if amendments will improve safe community disposal of used syringes and other sharps;
• making recommendations about community syringe disposal programs for the state or locality; and
• developing ways to educate the public about this issue and the recommended improvements.

The goal of these efforts is to create practical systems in the community for the safe disposal by patients and IDUs of used syringes and other sharps.

Signatures of Executives from Organizations