[Pharmwaste] RE: Trash Disposal of Pharmaceuticals Pharmwast e digest, Vol 1 # 83 - 2 msgs

Fri, 1 Jul 2005 13:43:40 -0400

Perhaps the IATP email below helps with a stab at an answer here? Stevan
Gressitt, M.D.

Antibiotics and the Food System
============================================================

Open access, freely available online
PLoS Medicine | www.plosmedicine.org <http://www.plosmedicine.org> August
2005 | Volume 2 | Issue 8 | e232

The Policy Forum allows health policy makers around the world to discuss
challenges and opportunities for improving health care in their societies.

Agricultural Antibiotics and Human Health

Does antibiotic use in agriculture have a greater impact than hospital use?

David L. Smith*, Jonathan Dushoff, J. Glenn Morris, Jr.

Like SARS, Ebola, and other emerging infectious diseases, antibiotic
resistance in bacteria may have a zoonotic origin [1]. Evidence suggests
that antibiotic use in agriculture has contributed to antibiotic resistance
in the pathogenic bacteria of humans, but the chain from cause to effect is
long and complicated. Antibiotic use clearly selects for antibiotic
resistance, but how far do these effects extend beyond the population where
antibiotics are used? Antibiotics and antibiotic-resistant bacteria (ARB)
are found in the air and soil around farms, in surface and ground water, in
wild animal populations, and on retail meat and poultry [2-9]. ARB are
carried into the kitchen on contaminated meat and poultry, where other foods
are cross-contaminated because of common unsafe handling practices [10,11].
Following ingestion, bacteria occasionally survive the formidable but
imperfect gastric barrier, and colonize the gut [12].

Patterns of colonization (asymptomatic carriage) and infection (symptomatic
carriage) in human populations provide additional evidence that ARB
occasionally move from animals to humans [13,14]. The strongest evidence
comes from the history of the use of antibiotics for growth promotion in
Europe. After first Denmark and then the European Union banned the use of
antibiotics for growth promotion, prevalence of resistant bacteria declined
in farm animals, in retail meat and poultry, and within the general human
population [8,15].

Despite the evidence linking bacterial antibiotic resistance on farms to
resistance in humans, the impact of agricultural antibiotic use remains
controversial [16-19] and poorly quantified. This is partly because of the
complex of population-level processes underlying the betweenspecies
("heterospecific") and withinspecies, host-to-host ("horizontal") spread of
ARB. To emerge as human pathogens, new strains of ARB must (1) evolve,
originating from mutations or gene transfer; (2) spread, usually
horizontally among humans or animals, but occasionally heterospecifically;
and (3) cause disease.

All three of these steps are complex and imperfectly understood. The
emergence of a new type of resistance is a highly random event, which can't
be predicted accurately, and may involve multiple steps that preclude
perfect understanding even after the fact. Spread is equally complicated and
may obscure the origins of resistance. In some cases, emergence of
resistance in one bacterial species is a consequence of the emergence and
spread in another species, followed by the transfer of resistance genes from
one bacterial species to another. Because of the underlying complexity,
mathematical models are necessary to develop theory-a qualitative
understanding of the underlying epidemiological processes [20-25]. Theory
helps researchers organize facts, identify missing information, design
surveillance, and analyze data [26].

Horizontal Transmission

Theory clearly shows that the impact of agricultural antibiotic use depends
on whether resistant bacteria have high, low, or intermediate horizontal
transmission rates in human populations [23,24]. The rate of horizontal
transmission among humans is determined by the underlying biology of the
pathogen, medical antibiotic use, and hospital infection control, but not by
agricultural antibiotic use [22]. On the other hand, a farm where multiple
antibiotics are used routinely, universally, and in low quantities for
growth promotion is likely to be an excellent environment for the evolution
of multiple resistance factors, including some variants that might never
have evolved in humans.Thus, even very rare transmission resulting from
agricultural antibiotics may have a medical impact by introducing new
resistant variants to the human population. The epidemiology of spread in
the human population dictates how the impact of agricultural antibiotic use
should be assessed.

Zoonotic pathogens, such as Campylobacter and Salmonella, are generally
regarded as having low horizontal transmission rates in human populations.
While resistance in zoonotic infections should be directly attributable to
resistance in the zoonotic reservoir, the impact of agricultural antibiotic
use remains controversial [18,27-29]. Zoonotic species could acquire
resistance genes from human commensal bacteria during the infection process,
but this hypothesis is difficult to test.

For pathogens with high horizontal transmission rates, resistant bacteria
will spread rapidly once they have emerged, and prevalence will be
maintained at a steady state by horizontal transmission. Thus, the impact of
subsequent heterospecific transmission is limited (Figure 1).
Nevertheless, one or two heterospecific transmission events could be
sufficient to cause the appearance of a highly successful ARB genotype in
humans, affecting the timing, nature, and extent of spread within the human
population[22]. Not only are such events difficult to trace, but their
impact is impossible to measure, since there is no way to know what type of
resistance would have appeared and with what temporal pattern, if transfers
from animals had been prevented. 

The case where horizontal human transmission rates are intermediate is
particularly interesting. If each case in a population generates
approximately one new case (a situation we call "quasi-epidemic"
transmission), each instance of heterospecific transmission will initiate a
long chain of horizontal transmission that eventually burns out.
Quasi-epidemic transmission can amplify a relatively low amount of
heterospecific transmission and substantially increase prevalence [23-25].
The effect is sustained as long as heterospecific transmission continues. A
corollary is that banning agricultural antibiotic use would have maximal
benefits if horizontal transmission is quasi-epidemic [24].
Moreover, the effects are most difficult to estimate because both
heterospecific and horizontal transmission must be accounted for. 

These principles apply to bacteria associated with outpatient antibiotic use
and  ommunity-acquired infections as well as those that are primarily
hospitalacquired. Although quasi-epidemic transmission would seem to be a
special case, it may in fact be the rule for many hospital-acquired bacteria
because it is the natural endpoint of the interplay between economics and
ecology [30]. By spending money on hospital infection control, hospital
administrators can reduce nosocomial transmission rates for resistant
bacteria. For example, hospitals may screen and isolate patients who are
likely to be carriers (i.e., active surveillance) and implement
infection-control measures, but this comes at the cost of isolating patients
[31]. Total costs are minimized by spending just enough to eliminate (or
nearly eliminate) the pathogen; thus, quasi-epidemic transmission is the
economic optimum [30]. 

The Community as a Reservoir for Resistance

Horizontal transmission is further complicated by population structure, such
as the movement of humans through hospitals and long-term care facilities.
Medical antibiotic use and horizontal transmission rates are high in
hospitals, but this is counterbalanced by short hospital stays.
An emerging view for hospital-acquired bacterial infections is that
persistent asymptomatic carriage plays a key role in the epidemic of
resistance. ARB can asymptomatically colonize a person for years: even if
the number of other people infected during a single hospital visit is less
than one, this number will exceed one when summed over several hospital
visits [25,32,33]. Thus, the ecological reservoir of resistance in the
community plays an important role in the increasing frequency of resistance
in hospital-acquired infections. Short hospital visits and long persistence
times of ARB in people guarantee that some of the costs associated with
failed infection control are passed on to other hospitals-new carriers are
frequently discharged from one hospital only to be admitted to another
hospital later [30]. Thus, the harm done by these ARB is borne by the whole
human population, particularly all of the health-care institutions that
serve a single catchment population.
In economic terms, the damage caused by the carriage of ARB is a kind of
pollution.

By comparing the total number of new carriers generated in the community,
the impacts of agricultural antibiotic use on hospitals can be compared
directly to the impact hospitals have on each other (Figure 2). The rate of
heterospecific transmission is intrinsically difficult to measure directly
because the risk of exposure and colonization per meal is very small.
Nevertheless, agricultural antibiotic use may generate as many carriers as
hospitals for the simple reason that the population experiences many more
meals than hospital discharges [34].
When agricultural and nosocomial transmission are equally rare in the
population, the latter will be much easier to identify and quantify.

A Natural Experiment: Glycopeptides and Vancomycin-Resistant Enterococci

Is the impact of agricultural antibiotic use on the emergence and spread of
ARB in humans large or small relative to medical antibiotic use? Put another
way, are farms or hospitals bigger polluters? A large-scale natural
experiment was conducted in the United States and several European countries
when each adopted different policies on glycopeptide use in animals
(avoparcin) and humans (vancomycin) [16,17,35-37]. Many European countries
approved avoparcin for animal growth promotion in the 1970s, but the US did
not. In the early 1980s, demand for vancomycin in US hospitals surged
because of increasing aminoglycoside resistance among enterococci and
methicillin resistance in Staphylococcus aureus.
Physicians in US hospitals also used oral vancomycin for some Clostridium
difficile infections [37-39]. In the late 1980s and early 1990s,
vancomycin-resistant enterococci (VRE) emerged and spread through US
health-care systems. In Europe, hospitals used less vancomycin because most
enterococci were sensitive to aminoglycosides, and oral vancomycin was
seldom used. VRE still emerged and spread through European hospitals, but
the problem has been less severe than in the US [40]. A different pattern
emerges for community prevalence of VRE. VRE are rarely found outside of
hospitals in the US, except for patients who have a prior history of
hospitalization. Community prevalence of VRE in the US is typically less
than 1%. In contrast, community prevalence of VRE was estimated at 2%-12% in
Europe during the late 1990s, including carriage by people with no history
of hospitalization [17,41-48]. In other words, the European community
reservoir generated by vancomycin use in hospitals and avoparcin use in
agriculture was apparently much larger than the US community reservoir
generated only by vancomycin use in hospitals. The prevalence of VRE in the
community declined after the EU banned avoparcin [15]. Thus, avoparcin is at
least partly responsible for the reservoir of VRE in the European community,
but how much of that reservoir came from avoparcin and how much came from
hospitals?

To weigh the impact, we subtract the community prevalence of VRE in the US
(<1%) from the community prevalence of VRE in Europe (>2%). The remainder
(>1%) is attributed to avoparcin. This analysis probably underestimates the
real impact because vancomycin was used less in European than in US
hospitals. Thus, avoparcin use in Europe would appear to be responsible for
generating a larger reservoir of VRE in the community than US hospitals. Put
another way, the impact of avoparcin use on European hospitals was larger
than the impact of US hospitals on one another.

Conclusion

Despite the evidence that avoparcin use has had a large impact on the
emergence and spread of VRE by increasing the reservoir of VRE in the EU,
some uncertainty continues to surround the clinical significance of VRE
strains of animal origin and of the zoonotic origins of resistance in
general. Bacterial strains circulating in hospitalized populations may be
genetically distinct from those circulating in the general human population
[13,17,49]. Thus, bacterial populations are some combination of zoonotic,
quasi-epidemic, and epidemic strains. The complexity of bacterial population
biology and genetics makes it practically impossible to trace bacteria (or
resistance factors) from the farm to the hospital, or to directly attribute
some fraction of new infections to agricultural antibiotic use.

Asymptomatic carriage of resistance factors by nonfocal commensal bacteria
adds to a general risk of resistance, but transfer of resistance among
bacterial species is unpredictable and difficult to quantify. Until more
evidence is available, it is prudent and reasonable to consider bacteria
with resistance genes a general threat [50-52].
Some part of the controversy over agricultural antibiotic use has been a
disagreement about how to weigh evidence and make decisions when the
underlying biological processes are complex. In this case, the effects of
agricultural antibiotic use on human health remain uncertain, despite
extensive investigation, and the effects may be unknowable, unprovable, or
immeasurable by the empirical standards of experimental biology. What should
be done when complexity makes an important public health effect
intrinsically difficult to measure? What is an appropriate "null hypothesis"
or its equivalent? Should the same standards of proof be used in science and
science-based policy? Where should the burden of proof fall? Scientific
assessments for policy should summarize the best state of the science,
recognizing that the burdens and standards of proof are necessarily softer
because of the uncertainty that is introduced by biological complexity. The
best decisions weigh the evidence in light of the inherent uncertainty. The
EU banned the use of antibiotics for growth promotion, based on the
precautionary principle.
The use of the precautionary principle was criticized by some as
unscientific in this context. In fact, the intrinsic problem of knowability,
posed by the biological complexity of the problem, makes the use of
precautionary decision making particularly suitable in this arena. The
assumption that plausible dangers are negligible, even when it is known that
such dangers are constitutively very difficult to measure, may be more
unscientific than the use of precaution. 

References

1. Taylor LH, Latham SM, Woolhouse MEJ (2001) Risk factors for human disease
emergence. Philos Trans R Soc Lond B Biol Sci 356: 983-989.

2. Hamscher G, Pawelzick HT, Sczesny S, Nau H, Hartung J (2003) Antibiotics
in dust originating from a pig-fattening farm: A new source of health hazard
for farmers? Environ Health Perspect 111: 1590-1594.

3. Zahn JA (2001) Evidence for transfer of tylosin and tylosin-resistant
bacteria in air from swine production facilities using sub-therapeutic
concentrations of Tylan in feed. J Anim Sci 79:189.

4. Iversen A, Kuhn I, Rahman M, Franklin A, Burman LG, et al. (2004)
Evidence for transmission between humans and the environment of a nosocomial
strain of Enterococcus faecium. Environ Microbiol 6: 55-59.

5. Gilliver MA, Bennett M, Begon M, Hazel SM, Hart CA (1999) Antibiotic
resistance found in wild rodents. Nature 401: 233-234.

6. Osterblad M, Norrdahl K, Korpimaki E, Huovinen P (2001) Antibiotic
resistance. How wild are wild mammals? Nature 409: 37-38. 

7. Chee-Sanford JC, Aminov RI, Krapac IJ, Garrigues-Jeanjean N, Mackie RI
(2001) Occurrence and diversity of tetracycline resistance genes in lagoons
and groundwater underlying two swine production facilities. Appl Environ
Microbiol 67: 1494-1502.

8. Emborg HD, Andersen JS, Seyfarth AM, Andersen SR, Boel J, et al.
(2003) Relations between the occurrence of resistance to antimicrobial
growth promoters among Enterococcus faecium isolated from broilers and
broiler meat. Int J Food Microbiol 84: 273-284.

9. Kmmerer K (2004) Resistance in the environment. J Antimicrob Chemother
54: 311-320.

10. Mattick K, Durham K, Domingue G, Jorgensen F, Sen M, et al. (2003) The
survival of foodborne pathogens during domestic washing-up and subsequent
transfer onto washing-up sponges, kitchen surfaces and food.
Int J Food Microbiol 85: 213-216.

11. Gorman R, Bloomfield S, Adley CC (2002) A study of cross-contamination
of food-borne pathogens in the domestic kitchen in the Republic of Ireland.
Int J Food Microbiol 76: 143-150.

12. Sorensen TL, Blom M, Monnet DL, Frimodt-Moller N, Poulsen RL, et al.
(2001) Transient intestinal carriage after ingestion of antibiotic-resistant
Enterococcus faecium from chicken and pork. N Engl J Med 345: 1161-1166.

13. Willems RJ, Top J, van den Braak N, van Belkum A, Endtz H, et al.
(2000) Host specificity of vancomycin-resistant Enterococcus faecium. J
Infect Dis 182: 816-823.

14. Bruinsma N, Willems RJL, van den Bogaard AE, van Santen-Verheuevel M,
London N, et al. (2002) Different levels of genetic homogeneity in
vancomycin-resistant and -susceptible Enterococcus faecium isolates from
different human and animal sources analyzed by amplified-fragment length
polymorphisms.Antimicrob Agents Chemother 46: 2779-2783. 

15. Aarestrup FM, Seyfarth AM, Emborg HD, Pedersen K, Hendriksen RS, et al.
(2001) Effect of abolishment of the use of antimicrobial agents for growth
promotion on occurrence of antimicrobial resistance in fecal enterococci
from food animals in Denmark. Antimicrob Agents Chemother
45: 2054-2059. 

16. Wegener HC, Aarestrup FM, Jensen LB, Mammerum AM, Bager F (1999) Use of
antimicrobial growth promoters in food animals and Enterococcus faecium
resistance to therapeutic antimicrobial drugs in Europe. Emerg Infect Dis 5:
329-335.

17. Bonten MJ, Willems R, Weinstein RA (2001) Vancomycin-resistant
enterococci: Why are they here, and where do they come from? Lancet Infect
Dis 1: 314-325. 

18. Phillips I, Casewell M, Cox T, de Groot B, Friis C, et al. (2004) Does
the use of antibiotics in food animals pose a risk to human health?
A critical review of published data. J Antimicrob Chemother 53: 28-52. 

19. Jensen VF, Neimann J, Hammerum AM, Molbak K, Wegener HC (2004) Does the
use of antibiotics in food animals pose a risk  to human health? An unbiased
review? J Antimicrob Chemother 54: 274-275. 

20. Bonten MJ, Austin DJ, Lipsitch M (2001) Understanding the spread of
antibiotic resistant pathogens in hospitals: Mathematical models as tools
for control. Clin Infect Dis 33: 1739-1746. 

21. Lipsitch M, Singer RS, Levin BR (2002) Antibiotics in agriculture:
When is it time to close the barn door? Proc Natl Acad Sci U S A 99:
S572-S574.

22. Smith DL, Harris AD, Johnson JA, Silbergeld EK, Morris JG Jr (2002)
Animal antibiotic use has an early but important impact on the emergence of
antibiotic resistance in human commensal bacteria. Proc Natl Acad Sci U S A
99: 6434-6439.

23. Smith DL, Johnson JA, Harris AD, Furuno JP, Perencevich EN, et al.
(2003) Assessing risks for a pre-emergent pathogen: Virginiamycin use and
the emergence of streptogramin resistance in Enterococcus faecium.
Lancet Infect Dis 3: 241-249.

24. Kelly L, Smith DL, Snary EL, Johnson JA, Harris AD, et al. (2004) Animal
growth promoters: To ban or not to ban? A risk assessment approach. Int J
Antimicrob Agents 24: 205-212.

25. Smith DL, Dushoff J, Perencevich EN, Harris AD, Levin SA (2004)
Persistent colonization and the spread of antibiotic resistance in
nosocomial pathogens: Resistance is a regional problem. Proc Natl Acad Sci U
S A 101: 3709-3714.

26. Becker NG (1989) Analysis of infectious disease data. London:
Chapman and Hall. 224 p. 27. Wegener HC, Aarestrup FM, Gerner-Smidt P, Bager
F (1999) Transfer of antibiotic resistant bacteria from animals to man. Acta
Vet Scand Suppl 92: 51-57.

28. Aarestrup FM, Engberg J (2001) Antimicrobial resistance of thermophilic
Campylobacter. Vet Res 32: 311-321. 29. Luber P, Wagner J, Hahn H, Bartelt E
(2003) Antimicrobial resistance in Campylobacter jejuni and Campylobacter
coli strains isolated in 1991 and 2001-2002 from poultry and humans in
Berlin, Germany. Antimicrob Agents Chemother
47: 3825-3830. 

30. Smith DL, Levin SA, Laxminarayan R (2005) Strategic interactions in
multi-institutional epidemics of antibiotic resistance. Proc Natl Acad Sci U
S A 102: 3153-3158. 

31. Perencevich EN, Fisman DN, Lipsitch M, Harris AD, Morris JG Jr, et al.
(2004) Projected benefits of active surveillance for vancomycin resistant
enterococci in intensive care units. Clin Infect Dis 38:
1108-1115. 

32. Bonten MJ, Hayden MK, Nathan C, Rice TW, Weinstein RA (1998) Stability
of vancomycinresistant enterococcal genotypes isolated from
long-term-colonized patients. J Infect Dis 177: 378-382.

33. Cooper BS, Medley GF, Stone SP, Kibbler CC, Cookson BD, et al.
(2004) Methicillinresistant Staphylococcus aureus in hospitals and the
community: Stealth dynamics and control catastrophes. Proc Natl Acad Sci U S
A 101:10223-10228.

34. Rose G (1992) The strategy of preventive medicine. Oxford: Oxford
University Press. 160 p. 35. Martone WJ (1998) Spread of vancomycinresistant
enterococci: Why did it happen in the United States?
Infect Control Hosp Epidemiol19: 539-545.

36. Cetinkaya Y, Falk P, Mayhall CG (2000) Vancomycin-resistant enterococci.
Clin Microbiol Rev 13: 686-707. 

37. Rice LB (2001) Emergence of vancomycinresistant enterococci. Emerg
Infect Dis 7: 183-187.

38. Morris JG Jr, Shay DK, Hebden JN, McCarter RJ Jr, Perdue BE, et al.
(1995) Enterococci resistant to multiple antimicrobial agents, including
vancomycin. Establishment of endemicity in a university medical center.
Ann Intern Med 123: 250-259.

39. Kirst HA, Thompson DG, Nicas TI (1998) Historical yearly usage of
vancomycin. Antimicrob Agents Chemother 42: 1303-1304. 

40. Schouten MA, Hoogkamp-Korstanje JA, Meis JF, Voss A, European VRE Study
Group (2000) Prevalence of vancomycin-resistant enterococci in Europe. Eur J
Clin Microbiol Infect Dis 19: 816-822.

41. van der Auwera P, Pensart N, Korten V, Murray BE, Leclercq R (1996)
Influence of oral glycopeptides on the fecal flora of human volunteers:
Selection of highly glycopeptideresistant enterococci. J Infect Dis 173:
1129-1136.

42. Gordts B, van Landuyt H, Ieven M, Vandamme P, Goossens H (1995)
Vancomycin-resistant enterococci colonizing the intestinal tracts of
hospitalized patients. J Clin Microbiol 33: 2842-2846.

43. Endtz HP, van den Braak N, van Belkum A, Kluytmans JA, Koeleman JG, et
al. (1997) Fecal carriage of vancomycin-resistant enterococci in
hospitalized patients and those living in the community in The Netherlands.
J Clin Microbiol 35: 3026-3031.

44. Schouten MA, Voss A, Hoogkamp-Korstanje JA (1997) VRE and meat.
Lancet 349: 1258. 

45. van den Braak N, Kreft A, van Belkum D, Verbrugh H, Endtz H (1997)
Vancomycinresistant enterococci in vegetarians. Lancet 350: 146-147.

46. van den Bogaard AE, Mertens P, London NH, Stobberingh EE (1997) High
prevalence of colonization with vancomycin- and pristinamycin-resistant
enterococci in healthy humans and pigs in The Netherlands: Is the addition
of antibiotics to animal feeds to blame? J Antimicrob Chemother
40: 454-456.

47. van den Braak N, van Belkum A, van Keulen M, Vliegenthart J, Verbrugh
HA, et al. (1998) Molecular characterization of vancomycinresistant
enterococci from hospitalized patients and poultry products in The
Netherlands. J Clin Microbiol 36: 1927-1932.

48. Stobberingh E, van den Bogaard A, London N, Driessen C, Top J, et al.
(1999) Enterococci with glycopeptide resistance in turkeys, turkey farmers,
turkey slaughterers, and (sub)urban residents in the south of The
Netherlands: Evidence for transmission of vancomycin resistance from animals
to humans? Antimicrob Agents Chemother 43: 2215-2221.

49. Leavis HL, Willems RJ, Top J, Spalburg E, Mascini EM, et al. (2003)
Epidemic and nonepidemic multidrug-resistant Enterococcus faecium. Emerg
Infect Dis 9: 1108-1115. 

50. Hammerum AM, Fussing V, Aarestrup FM, Wegener HC (2000) Characterization
of vancomycin-resistant and vancomycin susceptible Enterococcus faecium
isolates from humans, chickens, and pigs by RiboPrinting and pulsed-field
gel electrophoresis. J Antimicrob Chemother 45: 677-680.

51. Sundsfjord A, Simonsen GS, Courvalin P (2001) Human infections caused by
glycopeptide-resistant Enterococcus spp: Are they a zoonosis?
Clin Microbiol Infect 7(Suppl 4):16-33

52. Bogo Jensen L, Willems AE, van den Bogaard RJ (2003) Genetic
characterization of glycopeptide-resistant enterococci of human and animal
origin from mixed pig and poultry farms. APMIS 111: 669-772. 

============================================================
View the ARCHIVES of this list at:
http://lists.iatp.org/listarchive/

For help with listserv SUBSCRIPTIONS visit:
http://lists.iatp.org/listarchive/subscriptions.cfm

Questions, comments, concerns? Email us: support@iatp.org

-----Original Message-----
From: pharmwaste-admin@lists.dep.state.fl.us
[mailto:pharmwaste-admin@lists.dep.state.fl.us] On Behalf Of
JeffBeyer@co.manitowoc.wi.us
Sent: Friday, July 01, 2005 12:56 PM
To: Johnson, Emma (ECY)
Cc: 'Pistell, Ann E'; 'pharmwaste@lists.dep.state.fl.us';
pharmwaste-admin@lists.dep.state.fl.us
Subject: RE: [Pharmwaste] RE: Trash Disposal of Pharmaceuticals Pharmwast e
digest, Vol 1 # 83 - 2 msgs

In trying to learn more about this issue, is there any information where
there has been some indication of pharmaceutical poisons in the waste
water, that these releases where from the household dumping of
pharmaceuticals. Versus these trace indicators in the waste water being
from human by-products who where using these drugs. How do we know that the
test showing some tract of pharmaceutical products in water after being
processing by waste treatment plants is not from human by-products versus
flushing of the pharmaceutical waste by households. Or if it is a
combination of both what is the percentage of one versus the other.

Jeffery Beyer, Public Works Director, Manitowoc County

             "Johnson, Emma                                                
             (ECY)"                                                        
             <EJOH461@ECY.WA.G                                          To 
             OV>                       "'Pistell, Ann E'"                  
             Sent by:                  <Ann.E.Pistell@maine.gov>,          
             pharmwaste-admin@         "'pharmwaste@lists.dep.state.fl.us' 
             lists.dep.state.f         "                                   
             l.us                      <pharmwaste@lists.dep.state.fl.us>  
                                                                        cc 

             07/01/2005 10:36                                      Subject 
             AM                        RE: [Pharmwaste] RE: Trash Disposal 
                                       of Pharmaceuticals  Pharmwast       
                                       e digest, Vol 1 # 83 - 2 msgs       

In Washington State we looked at this issue as well.  Landfills on the
drier
eastside of our state either re-circulate their leachate or in some cases
are unlined.  However, landfills on the wetter westside of the state
discharge their leachate to waste water treatment facilities that use
secondary treatment.  We thought recirculation of leachate in an engineered
landfill was probably pretty good protection compared to discharge to WWTPs
or groundwater, so we weren't convinced at first that we should set up an
alternative disposal location.

However, three things that we realized:

1. It was impractical to educate consumers whether they should use the
trash
to dispose of pharmaceuticals based on who their waste hauler was.

2. As Ann mentioned, there is a pretty good reason that poison control
officials recommend flushing of unwanted medications-- security and safety
issues still exist for this material.  According to the Washington State
Department of Health, nine children die each year from poisoning, 465 are
hospitalized, and 3,490 visit the doctor.  Of 24 child poisoning deaths
from
1999 to 2001, 16 were due to medications.

3. There wasn't a logical environmental reason to allow HHW pharmaceuticals
into landfills when we spend a lot of time and money to keep other HHW
materials out of the landfill, especially if they have similar designating
characteristics.

Emma Johnson
Solid Waste and Financial Assistance
Washington State Department of Ecology

-----Original Message-----
From: pharmwaste-admin@lists.dep.state.fl.us
[mailto:pharmwaste-admin@lists.dep.state.fl.us] On Behalf Of Pistell, Ann E
Sent: Friday, July 01, 2005 8:12 AM
To: 'pharmwaste@lists.dep.state.fl.us'
Subject: [Pharmwaste] RE: Trash Disposal of Pharmaceuticals Pharmwaste
digest, Vol 1 # 83 - 2 msgs

In response to Ann Heil from Los Angeles?  I was taking a completely
provincial stand in that in Maine we don't have commercial landfills big
enough to treat their own leachate.(Sounds like your landfill does have its
own treatment plant.)  In Maine it all gets collected in tankers and taken
to the local POTW, which usually has secondary treatment only.

Also, I can't believe that we are any different than other states with
lined
landfills (We only have a few. Plus we still have a few that are unlined
with NO leachate collection at all.) We have monitoring wells outside all
landfill areas for the very reason that we know even lined landfills can
and
do leak, due to a variety of causes.(I was the project manager for the
largest commercial landfill in the state for several years, Waste
Management's, so I speak from personal experience!) This does point out
that
each state should develop disposal systems for their area - what works in
LA
may not be best in a rural state like Maine.

The journal I referred originally (see below) has several interesting
studies, many of which talk about the fate of pharmaceuticals during waste
water treatment/ bank filtration etc.  It is worth reading.

I think most would agree that landfilling would be better than flushing,
except those more concerned about diversion or accidental poisonings than
about environmental impacts.

Ann Pistell

Today's Topics:

   1. RE: Response: Trash Disposal of Pharmaceuticals (Volkman, Jennifer &
Charlotte Smith) (Heil, Ann)
   2. RE: RE: Trash Disposal of Pharmaceuticals (Contents of  Pharmwaste di
gest, Vol 1 #80 - 2 msgs) (Charlotte Smith)

--__--__--

Message: 1
Subject: RE: [Pharmwaste] Response: Trash Disposal of Pharmaceuticals
(Volkman, Jennifer & Charlotte Smith)
Date: Thu, 30 Jun 2005 14:51:28 -0700
From: "Heil, Ann" <AHeil@lacsd.org>
To: <pharmwaste@lists.dep.state.fl.us>

I don't buy either of these arguments. I work for an agency that = operates
both sewers and landfills. One very important fact to keep in = mind about
landfills is that the volume of landfill leachate produced is = very small.
A large landfill may only produce about 10,000 gallons per = day of
leachate.  It is MUCH easier to treat 10,000 gallons per day of = leachate
than 500 million gallons per day of wastewater.  I also don't = believe it
is correct to say that landfills will eventually leak.  = Modern landfills
are lined, with leachate collections systems.

While I don't believe that landfills are the best place for waste drugs, =
the drugs are much better off in a landfill than going down the toilet. =
The only way to get people to stop flushing drugs is to give them a =
reasonable alternative.  Pharmacy collection programs are not in place.  =
Many people will not take the trouble to go to a household hazardous =
waste
collection center or event.  I would rather have people putting = their
drugs in the trash, in a way that is not accessible to children or = pets,
than flushing them down the toilet.=20

Just to be clear - landfills are not the best place for drugs, but they =
are better places than sewers. If you want people not to flush, you have =
to give them an alternative that they will actually do.

Ann Heil
LACSD

-----Original Message-----
From: pharmwaste-admin@lists.dep.state.fl.us
[mailto:pharmwaste-admin@lists.dep.state.fl.us]On Behalf Of David Stitzhal
Sent: Thursday, June 30, 2005 7:44 AM
To: pharmwaste@lists.dep.state.fl.us
Subject: [Pharmwaste] Response: Trash Disposal of Pharmaceuticals (Volkman,
Jennifer & Charlotte Smith)

The two main arguments I hear about avoiding landfill disposal are,=20 in a
nutshell:

1). Landfill leachate is sent to wastewater treatment.  Given that=20 many
drugs are not captured in current treatment processes,=20 pharmaceuticals
that have migrated into the leachate can end up in=20 the environment.

2). All landfills will eventually leak, and the leachate will migrate=20 to
soil, and possibly groundwater, below and around the landfill.

--=20
David Stitzhal, MRP
President
Full Circle Environmental, Inc.
3111 37th Place South
Seattle, WA 98144
U.S.A.
206-723-0528 phone
206-723-2452 fax
stitzhal@fullcircleenvironmental.com
_______________________________________________
Pharmwaste mailing list
Pharmwaste@lists.dep.state.fl.us
http://lists.dep.state.fl.us/cgi-bin/mailman/listinfo/pharmwaste

--__--__--

Message: 2
From: "Charlotte Smith" <csmith@pharmecology.com>
To: "Charlotte A. Smith" <csmith@pharmecology.com>,
             "'Pistell, Ann E'" <Ann.E.Pistell@maine.gov>,
             <pharmwaste@lists.dep.state.fl.us>,
<dwyatt@centralsan.dst.ca.us>
Subject: RE: [Pharmwaste] RE: Trash Disposal of Pharmaceuticals (Contents
of
Pharmwaste di gest, Vol 1 #80 - 2 msgs)
Date: Thu, 30 Jun 2005 20:24:12 -0500

Alert reader Dr. Stevan Gressitt noted the fact that a number of
pharmaceuticals, including barium sulfate and lithium carbonate, are
actually inorganic chemicals which is absolutely correct. The vast =
majority of drugs are, however, organic molecules and need to be considered
as = such when disposal methods are discussed.  Thank you, Steve, for
catching  = that over-generalization.=20

Charlotte A. Smith, R. Ph., M.S., HEM
President
PharmEcology Associates, LLC
200 S. Executive Drive, Suite 101
Brookfield, WI 53005
Phone: 262-814-2635
Fax: 414-479-9941
csmith@pharmecology.com

-----Original Message-----
From: Charlotte A. Smith=20
Sent: Thursday, June 30, 2005 8:41 AM
To: 'Pistell, Ann E'; 'pharmwaste@lists.dep.state.fl.us';
'dwyatt@centralsan.dst.ca.us'
Subject: RE: [Pharmwaste] RE: Trash Disposal of Pharmaceuticals = (Contents
of Pharmwaste di gest, Vol 1 #80 - 2 msgs)

Thank you, Ann, for the citation. Yes, pharmaceuticals are organic
chemicals. When you mention emission controls for the pharma industry, =
are
you referring to the manufacturers running their own incinerators? I =
believe many of those have shut down. It is my understanding that RCRA =
incinerators are well scrubbed and monitored. Waste to energy plants and
other = municipal incinerators I believe need to meet certain emissions
criteria to accept non-hazardous pharmaceutical waste. I believe there is a
great deal more variance there. Of course, they may be getting small
amounts
of drugs in consumer waste. Anyone else have comments on the relative
benefits of incineration vs. landfilling?=20

Charlotte A. Smith, R. Ph., M.S., HEM
President
PharmEcology Associates, LLC
200 S. Executive Drive, Suite 101
Brookfield, WI 53005
262-814-2635
Fax 414-479-9941
www.pharmecology.com
H2E Champion for Change Award

-----Original Message-----
From: Pistell, Ann E [mailto:Ann.E.Pistell@maine.gov]=20
Sent: Thursday, June 30, 2005 7:37 AM
To: 'pharmwaste@lists.dep.state.fl.us'; 'dwyatt@centralsan.dst.ca.us'
Subject: [Pharmwaste] RE: Trash Disposal of Pharmaceuticals (Contents of
Pharmwaste di gest, Vol 1 #80 - 2 msgs)

 The bottom line is this - all landfills eventually leak. The more
sophisticated one have leachate collection, which goes to a treatment =
plant and is eventually discharged to a receiving water or bulked into
sludge which may then be land spread on crop land.  We all know that
treatment plants in the US, for the most part, do not have the processes to
= capture the pharmaceuticals. =20

An interesting article on this appears in "Ground Water Monitoring and
Remediation 24, No.2/Spring 2004, pages 119-126.  Title is =
"Pharmaceuticals and Other Organic Waste Water Contaminants Within a
Leachate Plume Downgradient of a Municipal Landfill" K. Barnes, S.
Christenson et.al.

I am sure there are other articles on this if one goes looking.  The = data
that may be sorely lacking is on air emissions - although I haven't dug =
deep for it. I am concerned about cross-media transfer, that by burning we
=
may be adding stuff to the air or the ash.  I think the general feeling is
that = by burning, the organics break down to harmless components, but I
would = like to see where that has been confirmed.  And, I am no expert nor
chemist, but = are some pharmaceuticals not (basically) organics???=20

Lastly, I know EPA has set emission limits for the pharmaceutical =
industry
which one would hope is based on stack tests etc., sound science.  = Anyone
looked at these?

Ann Pistell
Me DEP

Today's Topics:

   1. FW: Trash Disposal of Pharmaceuticals (Charlotte A. Smith)
   2. RE: FW: Trash Disposal of Pharmaceuticals (Volkman, Jennifer)

Date: Wed, 29 Jun 2005 11:50:42 -0500
From: "Charlotte A. Smith" <csmith@pharmecology.com>
To: <pharmwaste@lists.dep.state.fl.us>
Subject: [Pharmwaste] FW: Trash Disposal of Pharmaceuticals

Can anyone provide more information on landfill restrictions and why
hazardous waste incineration is a better solution environmentally at = this
point?  Thanks much!=3D20

Charlotte A. Smith, R. Ph., M.S., HEM
President
PharmEcology Associates, LLC
200 S. Executive Drive, Suite 101
Brookfield, WI 53005
262-814-2635
Fax 414-479-9941
www.pharmecology.com
H2E Champion for Change Award

-----Original Message-----
From: David Wyatt [mailto:DWYATT@centralsan.dst.ca.us]=3D20
Sent: Thursday, June 23, 2005 5:03 PM
To: Charlotte A. Smith
Subject: Trash Disposal of Pharmaceuticals

Good afternoon,

My name is David Wyatt and I am with the Central Contra Costa Sanitary
District (you will be speaking at a workshop here on the 19th of July). = I
am a Senior Technician at the Districts household hazardous waste =
collection facility (HHWCF).  We are looking for some information on the
effects of pharmaceuticals thrown in the trash.

We currently collect pharmaceuticals from households in our service area =
at our HHWCF.  The medications are packaged with poisonous materials and =
sent for incineration.  The cost of this waste stream is relatively =
inexpensive with respect to the rest of our waste costs.

I've been asked to find out why our residents cannot just throw them in =
the trash as mentioned in many reports.  Do you know of any publications =
that could provide us with information on the potential effects of
pharmaceuticals to sanitary landfills or do you know any other reasons =
why
residents should not put them in the trash?=3D20

We at the HHWCF feel accepting medications at our facility is the best =
and
only method of proper disposal of household pharmaceuticals.  We only =
need
to educate some of our management to see it that way.

Any and all information will be greatly appreciated.  You may reply to =
this email or give me a call at (925)335-7714.

Thank you for your time. Have a great day!

David Wyatt
Sr. HHW Technician
Central Contra Costa=3D20
Sanitary District - HHWCF
5019 Imhoff Place
Martinez, CA 94553
Ph.  925-335-7714
Fax  925-335-7737
dwyatt@centralsan.dst.ca.us
www.centralsan.org

------_=3D_NextPart_001_01C57CCA.B0131F57
Content-Type: text/plain;
             name=3D"David Wyatt.vcf"
Content-Transfer-Encoding: base64
Content-Description: David Wyatt.vcf
Content-Disposition: attachment;
             filename=3D"David Wyatt.vcf"

QkVHSU46VkNBUkQNClZFUlNJT046Mi4xDQpYLUdXVFlQRTpVU0VSDQpGTjpEYXZpZCBXeWF0d=
A0K
RU1BSUw7V09SSztQUkVGO05HVzpEV1lBVFRAY2VudHJhbHNhbi5kc3QuY2EudXMNCk46V3lhd=
HQ7
RGF2aWQNCkVORDpWQ0FSRA0KDQo=3D

------_=3D_NextPart_001_01C57CCA.B0131F57--

-- __--__--

Message: 2
Subject: RE: [Pharmwaste] FW: Trash Disposal of Pharmaceuticals
Date: Wed, 29 Jun 2005 17:50:51 -0500
From: "Volkman, Jennifer" <Jennifer.Volkman@state.mn.us>
To: "Charlotte A. Smith" <csmith@pharmecology.com>,
             <pharmwaste@lists.dep.state.fl.us>

In MN, we don't have a landfill restriction or ban on pharms.

We'd be interested in actual study data.  The basic concern from our SW =
=3D people here is that the pharms would eventually leach through the =3D =
garbage and show up in the leachate which is eventually run through the =3D
same = WWTP we were trying to keep it out of, or that the landfill would
=3D
= eventually leak and the pharms would move into groundwater. =3D20

With the lack of hard data, leachate contamination is only assumed, as =
=3D
is the relative ability of a landfill to attenuate or absorb pharms. =3D
Incineration appears to be the best option for destruction, as with any =
=3D other poison. =3D20

-----Original Message-----
From: pharmwaste-admin@lists.dep.state.fl.us
[mailto:pharmwaste-admin@lists.dep.state.fl.us]On Behalf Of Charlotte A.
Smith
Sent: Wednesday, June 29, 2005 11:51 AM
To: pharmwaste@lists.dep.state.fl.us
Subject: [Pharmwaste] FW: Trash Disposal of Pharmaceuticals