Pharmaceutical Waste Management Minimization by xmv12517

VIEWS: 308 PAGES: 64

									Pharmaceutical Waste
   Management &
    Minimization

       Janet Bowen, EPA
 NEHES Conference, March 21, 2008
      Overview of Presentation
• Environmental impacts of prescription drugs
• Review of 10-Step Blueprint including Regulatory
  Requirements
• Federal role: White House disposal guidelines,
  research, & policy implications
• Stewardship activities – state programs
• Region II enforcement summary
• Additional Programs
    1st National Study Revealed Extent of
             Pharms in Waterways
• USGS “Reconnaissance” study in 1999-2000 was
  1st nationwide investigation of pharms, hormones,
  & other organic contaminants in 139 streams in 30
  states:
  – 82 of 95 antibiotics, prescription & non-prescrip drugs,
    steroids, & hormones were found in at least 1 sample
  – 80% streams had 1 or more contaminant
  – 75% streams contained 2 or more
  – 54% had more than 5
  – 34% had more than 10
  – 13% tested positive for more than 20 targeted contaminants
      National & International Studies Have
                    Shown…
• Male fish, alligators, frogs, & other species with female organs &
  eggs
• Declines in human sperm counts, rise in female infertility
• Pharm compounds found at wastewater treatment plants
• Anti-cholesterol drug nearly killed test fish
• Cocktail of 13 drugs inhibited kidney cell growth
• Prozac linked to premature release of mussel larvae
• Associated Press Probe finds drugs in drinking water

• National Pharm Listserve
http://lists.dep.state.fl.us/cgi-bin/mailman/listinfo/pharmwaste
How Pharmaceuticals enter the
       Environment
Two Routes

• Excretion of unmetabolized medications
• Waste of unused medications
PURPOSEFUL   INADVERTENT
Concerns with Pharmaceuticals
• May degrade quickly, but constant input to water
• Possible subtle effects, even at ppb
• Chlorine in DW or WW makes some pharm by-
  products more toxic
• Unknown toxicants, in unknown amounts, in varied
  conditions either singly or in combination with other
  potential toxicants
• Potential for cumulative and synergistic effects from
  multiple exposures
• More questions than answers about effects of
  pharms on aquatic species & human health
 Why Can’t We Take the PPCPs out of the
                Water?
• POTWs are not designed to remove PPCPs
• Promising technologies include:
   –   Oxidation
   –   Ozonation
   –   Ultrasound
   –   Activated carbon
   –   Reverse osmosis
• Longer retention times (POTWs with nutrient removal)
  look promising
• Focus on controlling disposal at source
Managing Pharmaceutical Waste:10
  Step Blueprint for Health Care
            Facilities
  Introduction to a pharmaceutical waste
 management tool – use it to implement a
pharmaceutical waste management system!
                  http://www.h2e-
   online.org/docs/h2epharmablueprint41506.pdf
      Review of the 10 Steps
Step 1 Getting Started
  – Support from Senior Management
  – Develop a Committee
  – Plan for opportunities, challenges and
    financial implications to making changes,
    improvements in your facility.
    Step 2: Understanding the Regulations
        Hazardous Waste Background

   What is Hazardous Waste:
     • Waste that is dangerous or potentially harmful to human
       health or the environment
     • Can be liquids, solids, contained gases, or sludges




   Hazardous waste is regulated under the Resource
    Conservation and Recovery Act (RCRA):
     • Appears on one of the four hazardous wastes lists (P-list,
       U-list, F-list, or K-list)
     • Or exhibits at least one of four characteristics (Ignitability,
       Corrosivity, Reactivity, or Toxicity)
Hazardous Waste Background
  • In all states, the Environmental Department is the agency
    authorized to regulate hazardous waste under RCRA

  • A discarded pharmaceutical may be identified as a
    hazardous waste if it appears on a regulatory list of
    hazardous wastes (P or U) or exhibits one of four
    hazardous characteristics (ignitability, corrosivity,
    reactivity or toxicity)

  Healthcare Environmental Resource Center
  www.hercenter.org
  Step 2 Understanding the Regulations
            P-Listed Wastes
• P-Listed Wastes
  – Sole active ingredient
  – Unused – drug has not been given to a patient
• Empty Containers
  – Empty if triple rinsed
  – Rinsate must be managed as hazardous waste
  – Rinsing generally not practical for pharmaceutical
    waste
    Hazardous Waste:                                                 Listed
   If the pharmaceuticals you are using appears on these lists, the
    waste must be handled as a hazardous waste

   Common P-Listed Pharmaceuticals:

     Arsenic trioxide                       P012
     Epinephrine                            P042
     Nicotine                               P075
     Nitroglycerin                          P081
     Physostigmine                          P204
     Physostigmine salicylate               P188
     Warfarin >0.3%                         P001


     •   Please note that this list is not intended to be complete. The full list of all P-
         listed wastes appear in the Code of Federal Regulations, 40 CFR 261.33.
    Step 2 Understanding the Regulations
       Regulatory Interpretation:
          Epinephrine Salts
• October 15, 2007 EPA Memo
 http://www.epa.gov/region1/healthcare/pdfs/EpiMemo_Final.pdf


• Epinephrine salts are not a P042 listed
  waste (federally)

• States are delegated the RCRA program
  and can be more stringent
      Step 2 Understanding the Regulations
          Nitroglycerin Exemption
• Medical nitroglycerin removed as a P-listed waste
   – Weak, non-reactive, formulation

• Some formulations may fail ignitability characteristic
   – Waste injectables
   – Aerosols


• State may be more stringent (or may be still adopting the
  rule) – check with your state on their position on
  Nitroglycerin
    Step 2 Understanding the Regulations
           U-Listed Wastes
• U-listed Wastes
 – Sole active ingredient
 – Unused
• Empty Containers
 – All contents have been removed that can be
   removed through normal means and no more
   than 3% by weight remains
 – Residues removed from container must be
   managed as hazardous waste
    Hazardous Waste:                                                   Listed
   Common U-Listed Pharmaceuticals
    Chloral Hydrate (CIV)2   U034   Mitomycin C (chemo)         U010
    Chlorambucil (chemo)     U035   Paraldehyde (CIV)2          U182
    Chloroform               U044   Phenacetin                  U187
    Cyclophosphamide
                             U058   Phenol                      U188
    (chemo)
    Daunomycin (chemo)       U059   Reserpine                   U200
    Dichlorodifluromethane   U075   Resorcinol                  U201
    Diethylstilbestrol       U089   Saccharin                   U202
    Formaldehyde             U122   Selenium sulfide            U205
    Hexachlorophene          U132   Streptozotocin (chemo)      U206
    Lindane                  U129   Trichloromonofluromethane   U121
    Melphalan (chemo)        U150   Uracil mustard (chemo)      U237
    Mercury                  U151   Warfarin <0.3%              U248


    •   Please note that this list is not intended to be complete. The full list of all U-
        listed wastes appear in the Code of Federal Regulations, 40 CFR 261.33.
    Hazardous Waste:                           Characteristic

   If the pharmaceuticals you are using exhibits one of four
    hazardous characteristics, the waste must be handled as a
    hazardous waste

   Ignitability - having a flash point less than 60oC
     • Ignitable Characteristic Pharmaceuticals:
            Any formulations with more than 24% alcohol
            Oxidizers such as Potassium Permanganate and
             Silver Nitrate
            Collodion

   Corrosivity - having a pH less than 2 or greater than 12.5
     • Corrosive Characteristic Pharmaceuticals:
            Compounding Agents such as Glacial acetic acid and
             Sodium Hydroxide
    Hazardous Waste:                   Characteristic
   Reactivity - liable to explode, or react violently or release
    toxic gases when in contact with water
     • Reactive Characteristic Pharmaceuticals:
            Nitroglycerin



   Toxicity - containing a regulated substance at a
    concentration above the limit
     • Toxic Characteristic Pharmaceuticals:
            Zinc (some shampoos)
            Selenium
    How does this apply to Pharmacy?
   Facilities that generate hazardous waste
    are regulated as one of the following:
    • Conditionally Exempt Small Quantity Generators
      (CESQGs) Generate less than 100 kg of hazardous
      waste per calendar month*

    • Small Quantity Generators (SQGs)
      Generate between 100 kg and 1000 kg of hazardous
      waste per calendar month*

    • Large Quantity Generators (LQGs)
      Generate greater than 1000 kg of hazardous waste per
      calendar month

    *    And no more than 1 kg (2.2 lbs) of acutely
        hazardous waste per calendar month counts
        weight of container
Step 3 Consider Best Management
  Practices (BMPs) for Non-Regulated
  Pharmaceutical Wastes
  – Recommendations made for how to manage
    pharmaceutical waste to protect water bodies,
    aquatic species, human health.
       – Incineration (endocrine disruptors, carcinogenic
         drugs, Formulations w/listed active ingredient
         that is not the sole active ingredient, etc.)
       – Eliminate drain disposal
       – Avoid Landfilling
       – Use non PVC IV Sets
               Step 3 - BMPs
Managing to the Highest Standard
• Hazardous waste regulations have not
  kept pace with drug development
• Approximately 10% of the drugs that are
  not regulated are equally as hazardous.
• Best management practices encourage
  managing drugs that are equally harmful
  as hazardous waste when discarded
             Step 3 - BMPs
Dartmouth Hitchcock Medical Center Waste
       Characterization Summary

                  5%
                       11%

                                Federally
                                Hazardous
                                BMP
                                Hazardous
                                Non
                                Hazardous
            84%
                  Step 3 - BMPs
              Summary BMPs
•   Drugs with more than one active ingredient
•   All chemotherapy drugs
•   Drugs meeting OSHA and NIOSH criteria
•   Drugs on:
    – OSHA Technical Manual Appendix
    – DHHS list of carcinogens
• Drugs with low oral LD 50s
• Endocrine disruptors
• Vitamin and mineral preparations
• Contaminated PPE and spill clean
  up material
• Eliminate drain disposal
Step 4 Perform Review of Drug Inventory
• Obtain purchasing data from Drug Wholesaler
  and/or purchasing records
  – Identify ingredients
  – Determine RCRA hazardous waste code
  – Consider Compounded Items & Reformulations
• Gather Drug-Specific Data – national drug
  code, brand name, generic name, Mfr, strength,
  dosage form, package size
• Document decision making process
• Keep the review current
Step 5 Minimizing Pharmaceutical Waste
1. Consider lifecycle Impacts in Purchasing Process
     –     Longer expiration date
           •   Some epinephrine products have longer shelf life than others to
               minimize waste from crash carts and other areas where the
               drug is stored for emergencies
     –     Products with less packaging
           •   Packaging in contact with RCRA P-listed drugs must be
               managed as hazardous waste
     –     Products without hazardous preservatives
2.       Maximize Use of Opened Chemotherapy Vials
3.       Implement Samples Policy
4.       Labeling Drugs for Home Use
5.       Priming & Flushing IV lines w/Saline Solution
6.       Examine Size of Containers Relative to Use
Step 5 Minimizing Pharmaceutical Waste
    (cont’d)
7. Replace Prepackaged Unit Dose
    Liquids w/Patient-Specific Oral Syringes
8. Try to eliminate generation of controlled
    substances that are also hazardous
    wastes
9. Use hard plastic buckets for delivery of
    chemotherapy drugs to hospital floors –
    not brown paper bags
10. Monitor dating on emergency syringes
11. Review inventory controls to
    minimize outdates
 Step 5 Minimizing Pharmaceutical
           Waste (cont’d)
• Limitations on less hazardous drug
  substitution
  – Hazardous nature of drug often provides
    therapeutic effect
• Always ask:
  – What pharmaceuticals are being wasted?
  – Why are they being wasted?
  – How can wasting be minimized?
Step 6 Assess Current Practices
  –Conduct Department Reviews
  –Conduct Analyses Frequently
  –Confirm your Generator Status
Step 7 Taking On Communication Labeling
  Challenge
• Automating the Labeling Process
• Manually Labeling in the Pharmacy
• Providing Guidance on the Floor
• Selecting a Message for the Label
• Advocate that distributors        or
  manufactures label drugs            further
  up the food chain
Step 8 Consider Management Options
• Segregation at the Point of Generation
• Centralizing Segregation
• Managing all drug waste as hazardous
  – May be simplest and most economical
    approach for small facilities with < 50 beds
  – May cost large metropolitan facilities in
    excess of $1M
Sample Guidance Poster
Step 9 Getting Ready for Implementation
• Locating Your Satellite Accumulation
  Areas
• Evaluating Your Storage Accumulation
  Area
• Selecting the Right Vendors
• Conducting Pilots
• Putting it all together: Policies and
  Procedures
• Preparing for Spills
 Locating Satellite Accumulation
             Areas
• Located at the point of generation and under control of
  operator (check with state)
   – Soiled utility room in nursing unit
   – Sterile processing clean room and other areas of
     pharmacy
• Hazardous waste label
• Signage indicating Satellite Accumulation
• Keep container covered when not in active use
• Quantity Limit
   – Up to 1 quart of P listed waste and 55 gallons of combined U
     and characteristic waste
• Have 3 days to move when limit is reached
Step 10 Launch the Program
• Educate & Train Staff
• Staging the Roll-out
• Paperwork Requirements: Filling
  Out Required Forms
  – Hazardous Waste Manifests
  – Land Disposal Restrictions
• Tracking, Measuring &
  Recording Progress
   Federal Role:
 Agency Interests
     Research
Policy Implications
Disposal Guidelines
    EPA Regulatory Agenda
• Considering revising Universal Waste Rule
  for inclusion of some waste
  pharmaceuticals
• Office of Water evaluating the healthcare
  sector, including disposal of pharm waste
  from institutions, to determine need for
  development of WQ criteria
EPA’s Health Services Industry Detailed
Study
What is the Scope of the Study?
• We are studying the disposal of unused pharmaceutical from the
  Health Services Industry (hospitals and long-term care facilities) as
  part of the EPA’s CWA Effluent Guidelines Program
• We are looking to highlight good voluntary best management
  practices
What are We Studying?
• Identifying current management of unused pharmaceuticals at long-
  term care facilities and hospitals
• Summarizing federal, local, and regional requirements, guidance,
  and voluntary initiatives
• We are soliciting volunteers to fill out a data request
What is our Schedule?
• August 2008 Preliminary Report of Health Services



                        Health Services Industry Study Outreach
                                     January 2008
          Federal Disposal Guidelines
                Feb. 20, 2007
• Federal govt. guidelines for proper disposal of unwanted
  medications
   – ONDCP issued February 2007
   – Reaches across several Federal agencies
   – Encourages trash disposal—after drugs made
     unusable
   – Discourages flushing
   Federal Disposal Guidelines
• Take unwanted meds out of original containers & put
  in trash
• Mix prescription drugs with undesirable substance,
  (e.g., used coffee grounds or kitty litter) & put in
  impermeable, non-descript containers
• Flush only if label says to do so
   – FDA lists 13 pharms that should be flushed
• Use community return programs where available

   http://www.whitehousedrugpolicy.gov/drugfact/factsht/proper_dispo
      sal.html
               SMARxT Disposal
The SMARXT DISPOSAL campaign is designed to raise
awareness about the potential environmental impact from
improperly disposed of medications and to provide proactive
guidance through proper disposal alternatives.

SMARXT DISPOSAL is a unique public-private partnership
between the U.S. Fish and Wildlife Service, the American
Pharmacists Association, and the Pharmaceutical Research
and Manufacturers of America. This support and involvement
is what separates SMARXT DISPOSAL from other initiatives
and it will ultimately make this campaign successful.

Website just released!
SMARxTDisposal.net
Stewardship Activities
    Types of Stewardship Activities
•   1-time consumer return collections
•   Household haz waste collections
•   Permanent collection boxes
•   Use of police stations
•   Pilot use of reverse distributors
•   Pilot mail-back programs
•   Many of these programs require
    involvement of a pharmacist (DEA)
   EPA Stewardship Activities
• EPA’s new PPCP web site
 http://www.epa.gov/ppcp/
• 2 recently funded programs in Maine &
  Missouri thru Aging Initiative
  – Mail-back & take-back return programs
  – Inventories of types & quantities of drugs
    returned
 Northeast Recycling Council grant
Management of Unwanted Pharmaceuticals
• Researching and addressing legal issues with
  take-back programs,
• Developing drug collection pilots, including one
  nearby in South Portland, Maine,
• Developing a ―Guidebook for Holding Unwanted
  Medication Collections,‖
• Developing Best Management Practices for the
  end-of-life management of plastic medication
  containers.

Website – where you can download all materials
  http://www.nerc.org/projects/completed_projects.html#2006-a
             Results EPA Region II:
  Compliance Monitoring & Incentives Programs
                                                          Hospitals

         Universe
                                                             480

       Inspections
                                                              49

   Enforcement Actions                                        36

Formal Enforcement Actions                              11 ($1,523,613)

       Settlements                                       9 ($642,612)

    Audit Agreements                                          41

                                           156 covering 581 facilities ($29,947,688
  Voluntary Disclosures
                                                      for 143 resolved)
   Violations Corrected                                      3223
                    Adapted from Region 2 August 2006                          48
Healthcare Violations – All R2

                Breakout of Violations from Hospital Disclosures
      Emergency                                                     -Clean Air Act
      & Planning                                                   CAA Violations
  Community Right                                                       18%
   to Know - EPCRA
    Violations 7%                                                    - Clean Water Act
                                                                      CWA Violations
                                                                            4%


                                                                      Toxic Substance
                                                                     Control Act -TSCA
                                                                       Violations 1%

                                                           Safe Drinking
                                                          Water Act - SDWA
             -Hazardous Waste                              Violations 0%
              RCRA Violations
                   70%


                      Adapted from Region 2 August 2006                              49
                                 presentation
            Top 5 Violations
 (From 146 Voluntary Disclosures)
Rank   Violation                          Statute               Frequency

  1    ID of Hazardous Waste RCRA – Hazardous                   592
                                          waste

  2    Universal Waste                    RCRA– Hazardous       446
                                          waste

  3    Container                          RCRA– Hazardous       331
       Management                         waste

  4    Labeling                           RCRA– Hazardous       304
                                          waste

  5    CFC Leak Detection                 CAA – Clean Air Act   264
       Records
                   Adapted from Region 2 August 2006                  50
                              presentation
Healthcare RCRA Violations
        Breakout of RCRA Violations from Hospital Disclosures


                                                Generator
                          UST 3%             Requirements 5%


   Container
Management 30%                                                    ID of HW 26%




   General Facility
   Standards 10%                                          Universal Waste
                               Manifest 5%                     20%
         Accumulation Time
               1%


                      Adapted from Region 2 August 2006                          51
                                 presentation
   Region II Data – New Data
• Region II summer intern recently reviewed
  disclosures for "failure to identify" and
  "mischaracterization of HW" related
  violations.

• Data based on 100 hospitals
                                                                                                             Number of Violations
                                                                                                            (found in 100 facilities)
                            di
                              sp
                                     os
                                          ed
                                                  as




                                                                                              0
                                                                                                  20
                                                                                                       40
                                                                                                            60
                                                                                                                 80
                                                                                                                       100
                                                                                                                             120
                                                                                                                                   140
                                                                                                                                         160
                                                                                                                                               180
                                                                                                                                                     200
                                                        ge
                                                             ne
                                                               ra
                                                                       lw
                                                                               as
                       de                                                         t   e
                         te
                           rm
                                     in
                                          at
                                             io
                                                  n
                                                      be
                                                           fo
                                                              r   e
                                                                      di
                                                                         s  po
                     m                                                        sa
                       an                                                                l
                         ag
                                em
                                      en
                                            t(
                                                  la
                                                       be
                                                         ls
                                                             /le
         di                                                           ak
           sp
                os                                                       s   / li
                      ed                                                            ds
                                                                                      )
                           as
                                re
                                     gu
                                          la
                                             te
                                                d
                                                       m
                                                         ed
                                                           ic
                                                                  al
                                                                           wa
                                                                              s     te

                                     no
                                            di
la                                             s      po
                                                                                                                                                           Violation Type




  ck                                                    sa
       of                                                     lp
          d   oc                                                      ro
                                                                           ce
                 u   m                                                       du
                      en                                                             re
                        ta
                          t io
                                 n
                                      (c
                                           on
                                                  tra
                                                        ct
                                                          or
                                                               s/
                                                                 re
                                                                       cy
                                                                             cli
                                                                                                                                                                            Violation Type




                                                                                 n   g)




                                                               ab
                                                                 an
                                                                             do
                                                                                n    ed




                                                              tra
                                                                      ns
                                                                           po
                                                                              r     tin
                                                                                          g
                                                      Number of Violations
                                                      (Found in 100 Facilities)




                                            20
                                                 40
                                                        60
                                                                 80
                                                                          100
                                                                                  120
                                                                                        140
                                                                                              160




                                        0
          la
            b
                ch
                     em
                          ica
                                l




                       m
                           et
                             al

     ph
       ar
            m
             ac
                 eu
                    tic
                           al
                                s



            ae
              rs
                  ol
                       ca
                            ns

ch
     em
       ot
         he
                ra
                  pe
                       ut
                         ic
                                s




                   so
                        lve
                              nt
                                                                                                    Hazardous Waste Characterization




                  m
                     er
                          cu
                            ry
                                                                                                                               Characterization
                                                                                                                               Hazardous Waste




                        pa
                          in
                                    t




                           fil
                               m




                   al
                     co
                           ho
                             l
ENERGY STAR is…

    A voluntary partnership
           with EPA

    A strategic approach to
     energy management



                              55
       Energy Star Benchmarking
Healthcare Benchmarking
 - Evaluate your hospital’s energy perf
 - Healthcare benchmarking starter kit
www.energystar.gov/healthcare

Portfolio Manager to benchmark energy performance
  available for:
   - Acute care and children hospitals
   - Medical offices
   - Long Term Care, Assisted/Nursing Facilities (New)


                                                         56
New England Healthcare Facilities
     are Using Energy Star
• So far, 105 New England hospitals have
  benchmarked energy performance using
  Portfolio Manager : State breakdown (CT – 29;
  MA – 47, ME – 11; NH – 7; RI – 7; VT – 4)
• Benchmarking is the first step toward improving
  energy performance
• Three New England hospitals have earned
  ENERGY STAR Labels:
  – St. Francis (Hartford, CT)
  – VA West Haven, CT
  – VA Boston Healthcare system (Jamaica Plain)
                  Energy Star Program
                          E2C
Evaluate hospitals energy performance
 July 2006 ASHE commitment to improve energy efficiency in hospitals by
   10% Energy Efficiency Commitment - E2C
   http://www.ashe.org/ashe/facilities/e2c/index.html

Steps
1.   Benchmark and share with ASHE
2.   Leverage case studies, proven strategies, and networking opportunities
3.   Make improvements
4.   Apply for recognition from ASHE for 10% improvement

Resources

E2C Quick reference Guide
http://www.ashe.org/ashe/facilities/e2c/pdfs/e2cquickref.pdf


                                                                              58
            Energy Star
    Purchasing and Procurement
• Buy Energy Star Products
Product information
 Cost saving information, saving calculators
 Procurement information, sample language
http://www.energystar.gov/index.cfm?c=bulk_purc
  hasing.bus_purchasing

• Take free on-line procurement training,
http://energystar.premiereglobal.com/attendee/ConferenceList.aspx
     EnergyStar Key Resources
• Building Upgrade Manual
http://www.energystar.gov/index.cfm?c=business.bus_upgrade_manual


• New Building Guidance and Target Finder
http://www.energystar.gov/index.cfm?c=new_bldg_design.new_bldg_design

• Free EnergyStar Internet training
energystar.webex.com

• New! Use Benchmarking tool to track water consumption
  http://www.energystar.gov/index.cfm?c=business.bus_water



                                                                        60
                         Contact Us

Shubhada Kambli
EPA Region 1, ENERGY STAR
Boston, MA
617-918-1584
Kambli.Shubhada@epa.gov

Clark Reed
National Healthcare Manager, ENERGY STAR
Washington, D.C.
reed.clark@epa.gov




           www.energystar.gov/healthcare
                                           61
          General Resources
Healthcare Environment Resource Center
www.hercenter.org

Healthcare Without Harm
http://www.noharm.org/

Sustainable Hospital Project
http://www.sustainablehospitals.org/cgi-bin/DB_Index.cgi

Practice Green Health (includes former H2E)
http://www.h2e-online.org
                                                           62
      General Resources (Cont.)
• Building Healthy Hospitals: Top 5 Green Building
  Strategies for Healthcare (2007)

•   #1 Energy Efficiency
•   #2 Process Water Efficiency
•   #3 Sustainable Flooring Material Selection
•   #4 Indoor Air Quality: Material Selection
•   #5 Lighting Efficiency

http://www.epa.gov/region09/waste/p2/greenbldg.html
             Questions ?
Want to join EPA Region 1’s hospital email
 group for regular updates on
 environmental issues?

Janet Bowen, EPA Region 1
617-918-1795
Bowen.Janet@epa.gov
www.epa.gov/region1/healthcare

								
To top