Report of the Council on Scientific Affairs
Full Text

Safe Community Syringe Disposal:  Understanding the Barriers and Creating Solutions

Summary report of meeting sponsored by the American Medical Association, the Centers for Disease Control and Prevention, the American Association of Diabetes Educators, the American Pharmaceutical Association, and the Academy for Educational Development, Washington, DC, January 29-30, 2001.

Background 
Purpose of the Meeting 

Meeting Summary
Regulations Governing Disposal of Used Syringes
The Waste Management Perspective
The Federal OSHA Bloodborne Pathogens Standard
The Syringe Manufacturer’s Perspective
The Home Health Care Perspective
The Pharmacy Perspective
The Perspective of the Self-injector
Model Programs

Conclusions/Action Items 
NO-SSTIC Mission Statement  (Adopted September 2001)
References

Report Summary/Abstract

Background

The American Medical Association (AMA), the Centers for Disease Control and Prevention (CDC), the American Association of Diabetes Educators (AADE), the American Pharmaceutical Association (APhA), and the Academy for Educational Development (AED) co-sponsored a fact-finding meeting titled "Safe Community Syringe Disposal: Understanding the Barriers and Creating Solutions," which was held at the headquarters of the APhA in Washington, DC, on January 29-30, 2001. This meeting brought together more than 30 individuals representing the major stakeholders (see Appendix for listing of organizations represented at the meeting). This report summarizes the major information and action items that arose from this meeting.

NOTE ON TERMINOLOGY: For purposes of clarity, in this report "community" is defined as "outside of health care facilities." Thus, the disposal of used syringes within traditional health care venues where medical waste disposal guidelines exist is not the subject of the meeting or this report. Additionally, throughout the meeting, the terms "syringes," "needles," "lancets," and "sharps" were used interchangeably to indicate sharps with the potential to cause injury, and this interchangeable usage of  terms is reflected in this report as well.
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PURPOSE OF THE MEETING

The January 2001 meeting served as a launching platform to identify practical ways to improve options for safe community-level disposal of used syringes. The intent was to bring together key individuals with knowledge of the major subject areas and representatives from professional associations, industry, and public health to:

1. Identify and discuss major barriers to safe disposal of used syringes in community settings (ie, not health care facilities);
2. Formulate strategies for improving options for safe community disposal of used syringes; and
3. Develop an action plan for developing practical recommendations to improve safe syringe disposal options at the community level. It was anticipated that this small meeting would lead to additional actions, possibly including a larger meeting with a greater breadth of stakeholders.

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MEETING SUMMARY

In the community setting, at least 3 billion injections are administered yearly, resulting in the generation of many used syringes.^1,2 Unfortunately, the options for safe disposal of these syringes in the community are limited and where present, often are confusing and conflicting.³ Frequently, self-injectors do not know how to dispose of their used syringes, and physicians, pharmacists, and diabetes educators, the people they would most likely turn to for help, are uncertain of what to advise.

Potential problems that can arise from improperly discarded syringes include needlestick injuries, both occupational and non-occupational, and the potential transmission of bloodborne pathogens. Fear of injury or infection and the general offense to the senses when a used syringe is seen in community settings should not be underestimated.^1,4 Furthermore, the cost of providing post-injury counseling and prevention therapy to someone incurring a needlestick injury may be significant. Thus, safe community disposal of used syringes is a significant public health issue.⁴

Several barriers exist to solving this problem.^1,3 Cost may be the most important barrier; namely, who will pay for the safe disposal of syringes in the community? Also, who is responsible for developing and implementing programs that may facilitate safer community disposal of used syringes? Is it the local health department, the waste management industry, pharmacists, syringe manufacturers, or someone else? Or can it be a combination of different stakeholders? Laws and regulations affecting the safe community disposal of syringes are conflicting and differ from state to state, and even within different localities within a state. Also of importance are the local drug paraphernalia laws, which make it illegal to possess syringes for the purpose of injecting illegal drugs⁵ and could hamper programs attempting to collect used syringes. Other barriers include confusion due to the lack of clear guidance for syringe sellers and users as to what their responsibilities are and the lack of public health policy on this matter. Finally, the federal bloodborne pathogens standard is complex and many individuals and health care entities are uncertain as to when it would apply to them, should they decide to offer a community syringe disposal program.

There is no clear definition of what constitutes safe disposal of used syringes in the community. It can be the ideal of "zero" sharps in the trash/recycling municipal waste system due to programs ensuring that sharps are properly contained, or it could be zero sharps detected in the environment, or it could be that all used syringes go only into the medical waste stream. Obvious unacceptable situations are the disposal of used syringes on the ground and into storm drains or the sewage system and the "naked" disposal of used syringes into the municipal trash system. However, much controversy exists about what can be used to contain used syringes prior to their deposit into the municipal trash stream. Although frequently recommended by many guidelines, such as those from the Environmental Protection Agency (EPA)⁶ and patient guidelines produced by the AMA,⁷ "puncture resistant" containers, like a sealed coffee can, do NOT hold up in the municipal waste stream. However, until a more appropriate disposal system is available, it is inappropriate to discontinue this practice.

Some existing models for disposal include the distribution and/or sale of sharps containers along with syringes.^1,3 This requires a means by which these containers can be returned by the user, such as via pharmacies or mail, or at fire stations and hospitals. Alternatively, one-way "drop boxes" also can be used for accepting filled sharps containers. The placement of sharps-disposal containers in public places (eg, airplane restrooms, hotels, public restrooms) would also facilitate the disposal of used syringes by members of the public. However, while certain public areas are pursuing this approach, there is general resistance to doing so for aesthetic reasons and also due to a lack of data on the effectiveness and safety of such approaches.

Development of safety syringes also may help alleviate the problem; however, most safety devices require user activation, and are only useful as long as the syringe is not deposited in the municipal waste stream. In fact, Becton, Dickinson and Company (BD), the world’s largest manufacturer of syringes, clearly specifies that following activation of the safety device, the syringe still must be disposed of in a sharps container. Additionally, the use of safety syringes may not be practical for people with diabetes as many of these syringes can only draw once. Thus, at this time, the use of safety syringes is not significant in the community. Finally, syringe-exchange programs remain a useful way to dispose of used syringes. However, the challenges to implementing such programs are considerable, ranging from legislative barriers to funding to questions of stigmatization.

It is also critical that education about and promotion of safe disposal of used syringes occur not only in professional settings, such as physician offices and pharmacies, but also in more general and widespread manners, such as via the mainstream news media.
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Regulations Governing Disposal of Used Syringes

"Household" generated sharps have traditionally been unregulated and thus there are no clear general federal regulations governing the disposal of used syringes in the community. Existing federal guidelines are generally focused on protecting specific workers from potential exposure. Thus, the US Department of Transportation’s guidances on handling used syringes may differ from those provided by the US Postal Service. Most regulations, laws, and guidelines for safe community disposal of used syringes, if present, exist at the state and local levels, usually through infectious waste and solid waste policies.¹ The EPA has issued guidelines to consumers on how to dispose of their used sharps by placing them in a puncture-resistant container and then in the trash,⁶ but these guidelines are now being questioned as inappropriate.

A national project is underway--funded by the CDC and managed by the Academy for Educational Development--to assess the federal and state laws, regulations, and guidelines pertaining to syringe packaging, labeling, transportation, and disposal in the community. This study will also examine the community-generated sharps disposal programs currently operating in various states. It is anticipated that this study will also provide feedback on the effect of the regulations, policies, and prevention programs on community syringe disposal and additional information on other barriers to safe community disposal of used syringes through interviews with state regulators and with those involved in community syringe management programs. Data from this survey will be invaluable in addressing the problem.
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The Waste Management Perspective

Waste Management, Inc, which collects over 50% of the nation’s community waste, represented the perspective of the waste management industry at the January 2001 meeting. Waste from the community, so-called "municipal solid waste," is not regulated by the federal government and is treated very differently from medical waste, which is considered to be part of the special waste stream and which is federally regulated.

The general processing pathway for municipal solid waste is as follows:

1. Municipal solid waste is compacted in the garbage truck that collects the waste from the community. At this point, very few household containers survive the compaction, and the contents of most of these containers are released into the general waste. Thus, used syringes placed in household containers generally are released into the contents of the truck, posing potential injury hazards.
   
2. Garbage trucks take the compacted trash to a municipal recycling facility where the trash is deposited onto large conveyers and workers proceed to manually pick through the trash looking for items that can be recycled, including soda bottles, plastics, etc. At this point, there is a high risk of worker exposure to used syringes, whether or not they have been deposited in a household container. This processing step is expected to increase in frequency as more communities attempt to achieve a 50% recycle rate, potentially increasing the number of workers who will be exposed to community-disposed sharps.
   
3. The garbage is then taken to a transfer station where it is dumped onto a concrete floor and further compacted and then placed into tractor trailers. It is unlikely that any household container can survive this compaction process; thus, any container that was left in the trash from the recycling facility because it was labeled as not to be recycled, will likely fragment at this point, releasing its contents onto the concrete floor. This is another risk exposure for workers.
   
4. The tractor trailers take the compacted waste to either mass burn units (15%) where it is incinerated or to landfills (85%) where it may be compacted another time. Interestingly, there are case reports of workers being injured when they stepped on exposed needles in the landfill or when they service landfill vehicles.

Waste Management, Inc, states that its workers encounter sharps at all points of this process and that the greatest risks occur at the municipal recycling facilities.⁸ The industry defines an exposure to be an encounter with a used syringe, either visual or physical; an actual puncture injury is not necessary. The company is currently conducting a study of the rates of worker exposure to used syringes and expects to have the actual data available at the end of 2001.

Waste Management, Inc, has had some success with educating consumers on the safe disposal of syringes, but notes that while some counties have had great success at reducing the number of exposures of their municipal waste workers to used syringes, other have not. Problems include situations where used syringes are placed into plastic soda bottles and the bottles are then placed in the recycling cans, and a general lack of public compliance with available guidelines despite extensive outreach programs by the industry.

Finally, Waste Management, Inc, is piloting a trial program in three regions across the United States: Orange County, Denver and Orlando. This program relies on a 1993 approval by the US Postal Office allowing sharps transport by mail, provided the sharps containers are shipped by priority mail. The program involves a major campaign to educate community residents about the hazards of unsafe disposal of used syringes. The company provides free sharps containers to any person requesting them. When full, these containers are mailed back to Waste Management by the user, and postage is paid for by Waste Management. The estimated cost of such a program is $30 for the distribution, collection, and disposal of a one-gallon container of sharps (which can hold about 200 1-cc syringes). One of the benefits is the relative confidentiality provided to users.
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The Federal OSHA Bloodborne Pathogens Standard

Significant confusion exists about how the federal bloodborne pathogens standard affects safe community disposal of used syringes. Many meeting participants felt the standard actually dissuades many facilities, such as grocery stores and pharmacies, from offering programs to collect syringes as they believed they would then have to comply with what is generally perceived as a complex bloodborne pathogens standard.¹ However, it need not be that difficult.

First, the bloodborne pathogen standard is performance-oriented, which allows flexibility by the employer.⁹ Thus, it is up to the employer to determine the exposure risk for his or her facility, and if such a risk is "reasonably anticipated," the employer must follow the bloodborne pathogens standard. Importantly, if an employer determines that only one individual is at risk, it is possible to apply the standard only to that person and not the whole facility. However, all persons in the facility must be trained on how to handle a potential exposure situation. This could be as simple as isolating the contamination with barriers and then calling in the party responsible for remediation. This reduces the employer’s burden significantly, to the extent that the required exposure control plan may be as short as 2 pages.

Second, unless there is a trigger for OSHA inspection, such as an accident or the possibility of imminent danger of death or serious physical harm, facilities are rarely inspected, unless they are on the year’s "site-specific targeting" list. OSHA relies on complaints to prompt inspections.¹⁰

As of April 2001, the new bloodborne pathogens standard will require reporting of all sharps injuries to the OSHA 300 log, separate from the OSHA 200 log. This mandatory reporting requirement exempts physicians’ clinics and pharmacies, thus reducing the administrative burden for these "low risk" environments. This should facilitate these locations’ acceptance of used syringes if they so choose.
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The Syringe Manufacturer’s Perspective

Becton, Dickinson and Company (BD) provided the perspective of the manufacturing industry. With over 3.7 million people with diabetes using insulin twice a day, at least 2 to 3 billion sharps are generated per year in the community.¹ This does not include blood lancets and persons self-injecting other drugs such as antibiotics, cytotoxic drugs, etc. Reinforcing prior comments, BD also reports that disposal of these used syringes is often unregulated and patients are generally not aware of how to properly dispose of them. Stigma associated with syringe use and conditions like diabetes contributes to people not complying with guidances. People with diabetes may resent having to use sharps, are not aware of the rules of sharps disposal, and do not want to have spend more money on sharps disposal.

Used syringes pose a far greater hazard than most people realize. Small needles generate immense force--29-gauge needles easily penetrate the thick leather gloves worn by waste handlers. Very fine needles easily penetrate the plastics of proper disposal containers. Thus, proper syringe disposal requires that either the cannula be destroyed, or that the used sharps be deposited in proper home containers and adequately disposed of. However, most recommended techniques for cannula destruction do not work well and leave enough of the needle behind that injury can still occur. Sometimes needles separated from the syringe may pose an even greater hazard to the waste handler. Home disposal units, whether homemade or purchased, are unattractive and often inconvenient, and their ultimate disposal is a major problem. These containers should not be deposited in the municipal waste for the reasons detailed above, thus leaving the user with very limited options. There have been reports of users storing their used syringes indefinitely in a basement and leaving them there when they move. Thus, the used syringes enter the municipal waste stream.

Finally, BD believes that safety syringes will not solve for the problem. Even excluding cost considerations, safety syringes preclude the multiple draws that many people with diabetes must perform, require some practice to use, and still need to be disposed of in a proper container. BD believes that the problem of home disposal of sharps will only be resolved by a solution that is safe, convenient, inexpensive or reimbursed, and legislated.
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The Home Health Care Perspective

There are an estimated 20,000 formal home health care agencies in the United States. In 1996, home health care personnel served more than 268,000 people. While formal home health care agencies are regulated, private duty nurses and nursing agencies are not.

For the formal home health care providers, requirements for sharps disposal vary by state; thus, most formal home health care agencies provide their own individual guidelines. These generally include a requirement to use commercial sharps containers; a recommendation to use a chemical treatment, such as bleach; proper labeling instructions; and delivery of the sharps containers to a commercial biohazard waste service for disposal.

There are no regulatory requirements for syringe disposal for patients who inject regularly at home, perhaps due to the longstanding exemption of household-generated sharps from federal regulation, and efforts by home health care personnel to educate these persons vary tremendously. While most formal agencies provide educational materials to their patients, the private duty nursing agencies generally do not. Even then, the educational materials distributed by home health care workers are not ideal, calling for containment in a detergent bottle followed by disposal via the municipal waste system. Home health care agencies often express concern about the conflicting guidances issued by states for disposal of used syringes in the home. Their personnel frequently note that sharps containers in the home are not secure and can be easily accessed by children and that, even when guidance is provided to their patients, compliance is very low. Perhaps if patients more clearly understood the hazards of used syringes in the community, compliance would improve. Finally, the home health care industry is concerned about the transport of used syringes by their personnel to commercial medical waste disposal companies. Because sharps containers do not fill up rapidly, home health care personnel often carry the containers in their vehicles or store them at home until they are full. This is obviously not an optimum procedure.
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The Pharmacy Perspective

It has been suggested that the pharmacy would be an excellent location to accept used syringes for proper disposal. Indeed, the pharmacy is the primary distribution source for syringes, and because of frequent contact with the public could play an important educational role. Pharmacies where adult immunizations occur are already generating used sharps and meeting the bloodborne pathogens standard, and would theoretically be even better placed for accepting used syringes.

However, pharmacists are extremely concerned about compliance with OSHA’s bloodborne pathogens standard should they begin accepting used syringes from the community for disposal.¹ Should the pharmacist directly accept these syringes, the bloodborne pathogens standard would apply to the pharmacy, introducing additional administrative and training requirements that are viewed as onerous by many pharmacies. Additionally, the pharmacist would have to become familiar with the disposal requirements and available disposal programs in his or her local region. Further, in order to start accepting syringes, the pharmacy would have to overcome negative public perceptions and pharmacists’ attitudes. Many members of the community and the pharmacists themselves are concerned that accepting used syringes for disposal would open the pharmacy to visits by people deemed "socially unacceptable."¹⁰ For the pharmacy, this could result in lost revenue if customers go elsewhere.

Space would also have to be created for storage prior to pick up of used syringes by a medical waste company, and pharmacy storage space is very limited. Also, there will increased personnel and financial burdens, as pharmacists are already extremely busy. It is estimated that by the year 2004, there will be only a 6% increase in the number of pharmacists but a 44% increase in prescriptions needing to be filled.

However, the pharmacist community is aware of the public health hazards posed by improperly disposed syringes in the communities it serves. Thus, pharmacists recommend a 2-tiered approach to the problem. The first is education. Pharmacies can provide information to the public about the health hazards of the problem and hand out information on community disposal programs and syringe mail-back programs. The second tier would involve pharmacies actually serving as collection points for used syringe containers. Minneapolis, Miami, and San Francisco already have such pilot programs in place in their Walgreens pharmacies. A drop box that is directly picked up by the medical waste company is best because this allows the pharmacy to avoid direct contact with the sharps and may mean that the bloodborne pathogens standard does not apply.^1.9
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The Perspective of the Self-injector

The person with diabetes has to undergo significant behavioral changes. As such, disposal of used syringes often is lost in the complexity of dealing with the medical condition. Prior to an educational campaign by the American Diabetes Association in 1995, over 90% of persons with diabetes discarded their used sharps directly into the municipal waste stream.^1,9 A recent assessment by the American Association of Diabetes Educators revealed that over 43% of people with diabetes still do not use a puncture-proof container when disposing of their sharps in the trash. Less than 50% broke off the needle prior to discarding the used syringe. Interestingly, over 90% recapped their needles prior to disposal. Additionally, less than 43% of travelers brought containers to facilitate disposal of sharps in the trash and only 35% brought their sharps home for disposal. Thus, a significant injury risk is posed to hospitality staff, such as hotel chambermaids, who may be exposed to these sharps. Educational level, income, sex, or age do not influence these disposal habits. Only 55% of patients with diabetes recall being educated on the proper disposal of sharps in the community. Thus, education on safe syringe disposal must be further improved, but importantly, the risk of these unsafe disposal habits to others in the community also must be pointed out to the users.

Patients with diabetes have expressed frustration with some of the disposal issues. These include concerns with reuse of their syringes by others; not wanting to be identified as a person with diabetes; lack of access to puncture-resistant containers, particularly for those at lower income levels; lack of portability of the containers; and the complex and often confusing myriad of laws and regulations surrounding syringe disposal.

For the nonmedical injection drug user (IDU), proper syringe disposal practices are especially important. IDUs are frequently the most blamed for the appearance of used syringes in the community.³ Significantly, efforts to prevent HIV and hepatitis transmission by improving access to sterile syringes are often countered with concerns that the syringes will not be discarded safely, potentially exposing the community to bloodborne pathogens. An estimated 1 billion injections per year are performed by IDUs.¹⁰ With syringe reuse and sharing, it is unlikely that an equivalent number of used syringes are disposed of in the community. However, a recent survey of IDUs indicated that 72% disposed of their used syringes in the trash or a dumpster; 14% disposed of their syringes in the sewer, which ends up at the sewerage facility where workers are exposed; and 10% could not remember what happened to the syringes.

Unfortunately, there are many barriers to proper syringe disposal by IDUs, ranging from fear of arrest and identification as a drug user to the effects of the drugs they are injecting. However, IDUs do take steps to decrease risk to others, and those IDUs with medical reasons for use of syringes have better disposal practices. Thus, to facilitate better syringe disposal by IDUs, syringes need to be removed from the drug paraphernalia laws, and one-for-one syringe-exchange programs need to be further developed. Additionally, educational efforts must be directed at the IDU population. To facilitate proper disposal practices, law enforcement officials need to be educated on the relationship between unsafe disposal of used syringes and enforcing paraphernalia laws, and they should be urged to exempt individuals from arrest for possession of a limited number of syringes.
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Model Programs

Currently, New York State, San Francisco, Minneapolis and Wisconsin are localities that have model syringe disposal programs. California has enacted a law that will facilitate hospitals and health care facilities accepting home-generated sharps by simply amending their medical waste management plans and will facilitate the creation of "home-generated sharps consolidation points" by the local enforcement agency. San Francisco’s program is run by a coalition between the public health department and the medical waste companies. Almost all Walgreens pharmacies in San Francisco participate in this program, in which sharps containers are distributed and accepted back by pharmacies when full. The used containers are temporarily stored by the pharmacy, and medical waste haulers then pick up the biohazard boxes on a regular schedule. All this is done at no cost to the user. New York’s program is run through the New York State Department of Health and is part of a recently approved law to expand access to sterile syringes. While no legislation was enacted requiring pharmacies, physicians, and other entities issuing syringes to accept used syringes for disposal, an extensive outreach and education program has assured the participation of the majority of pharmacies in syringe-disposal programs. Wisconsin’s program is voluntary and is administered through the Department of Natural Resources but executed at the local level. Wisconsin, however, passed regulations that prohibited the landfilling of sharps without proper treatment. Also, Wisconsin facilitated the voluntary acceptance of used sharps by any facility by reducing the paperwork burden and providing supporting provisions in other laws. In developing these changes, Wisconsin recruited broad representation of stakeholders to the advisory group writing the new regulations, thus facilitating their acceptance following passage.
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Conclusions/Action Items

1. A coalition has been established to continue to address this public health problem. This coalition is called the "National Organizations for Sharps Safety and Training in the Community" or NO-SSTIC. Interest has been expressed by the waste management industry and the syringe manufacturing industry in funding coalition activities. The coalition has formed 5 workgroups, Legislation, Data Collection, Education, Coalition Development, and Disposal Options/Programs, which are charged to define their individual problems and provide recommendations to the coalition in March 2001. The necessity for a large scale meeting of stakeholders will be addressed following consideration of these recommendations.
   
2. The Mission Statement of this coalition is: 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. (Adopted September 2001)
3. The problem of safe syringe disposal in the community is complex, requiring multi-layered solutions focussed at the local levels.
   
4. Barriers to the solution 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. Additionally, definitive data are lacking on several issues surrounding community syringe disposal, such as the incidence of injuries sustained by workers in the community (hospitality staff, sanitation workers, etc), the current guidelines and regulations at the state and local level, the proper disposal of used sharps in the community (eg, in the municipal waste stream or reclassified as special waste). Thus, state legislation must be involved in addressing the barriers.
   
5. A definition and survey of the disposal options and model programs is needed and this is currently being undertaken by the Academy for Educational Development.
   
6. There is a critical need for an appropriate safe disposal guideline for self-injectors who will continue to deposit used syringes in the municipal waste.
   
7. A Web-based resource must be established that consolidates all state and local regulations and legislation on the issue and provides information for the user on proper syringe disposal in his/her community.
   
8. A problem identification statement must be developed that can be released to the news media and the public to increase awareness of the problem. This statement should be signed onto by all the associations and organizations that participated in the January 2001 meeting.
   
9. An e-mail listserv has been established for the coalition and is run through the AMA to facilitate idea exchange and communication between all members of the coalition.
   
10. Another stakeholder that needs to involved is the pharmaceutical industry. A strong trend towards non-injected drugs, eg, inhaled insulin, would reduce the use of syringes in the community. It is noted that several drugs that were injected 10 to-15 years ago are now available to be taken orally.

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Reports by topic 

   References

1. Macalino GE, Springer KW, Rahman ZS, Vlahov D, Jones TS. Community-based programs for safe disposal of used needles and syringes. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18 Suppl 1:S111-S119.
2. Lurie P, Jones TS, Foley J. A sterile syringe for every drug user injection: how many injections take place annually, and how might pharmacists contribute to syringe distribution? J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18 Suppl 1:S45-S51.
3. Centers for Disease Control and Prevention. Syringe Disposal Fact Sheet. Available at: http://www.cdc.gov/hiv/projects/idu-ta/facts/aed_idu_dis.htm. Accessed: 2-9-2001.
4. Agency for Toxic Substances and Disease Registry. The public health implications of medical waste: a report to Congress. Atlanta: US Department of Health and Human Services; 1990.
5. Springer KW, Sterk CE, Jones TS, Friedman L. Syringe disposal options for injection drug users: a community-based perspective. Subst Use Misuse. 1999;34:1917-1934.
6. United States Environmental Protection Agency. How to store and dispose of medical sharps. Available at: http://www.epa.gov/seahome/housewaste/src/sharps.htm. Accessed: 2-9-2001.
7. AMA Patient Guidelines on Sharps Disposal.
8. Turnberg WL, Frost F. Survey of occupational exposure of waste industry workers to infectious waste in Washington State. Am J Public Health. 1990;80:1262-1264.
9. Occupational Safety and Health Administration. Occupational Exposure to Bloodborne Pathogens; Needlestick and Other Sharps Injuries; Final Rule. Available at: http://www.osha-slc.gov/FedReg_osha_data/FED20010118A.html. Accessed: 2-9-2001.
10. Wright-De Aguero L, Weinstein B, Jones TS, Miles J. Impact of the change in Connecticut syringe prescription laws on pharmacy sales and pharmacy managers' practices. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18 Suppl 1:S102-S110.

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Reports by topic

Academy for Educational Development, Center for Community-based Health Strategies; The CHANGE Project

American Association of Diabetes Educators

American Foundation for AIDS Research

American Medical Association

American Pharmaceutical Association, Practice Development and Research

Becton, Dickinson and Company

Centers for Disease Control and Prevention, National Center for Infectious Diseases; Division of HIV/AIDS Prevention

Environmental Protection Agency, Office of Solid Waste

Food and Drug Administration

Grady Health System, Diabetes Unit (Atlanta, Ga)

National Association of Chain Drug Stores

National Association for Home Care

New York State Department of Health, Division of HIV Prevention, AIDS Institute

Occupational Safety and Health Administration, Office of Health Compliance Assistance

Sanitary Fill Company (San Francisco)

Sharps Compliance, Inc. (Houston, Texas)

Sheffield Health Authority (United Kingdom)

State of California Department of Health Services, Division of Drinking Water and Environmental Management

Walgreens Co.

Washington State Department of Health, Office of Environmental Health and Safety

Waste Management, Inc.

Wisconsin Department of Natural Resources, Bureau of Waste Management

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