The College of Optometrists

Infection control

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Sub-sections

Key points

  • Infection control is concerned with two main areas. Firstly, transmission from person to person, and secondly, transmission via a contaminated object.
  • You should practise appropriate hand hygiene to prevent the spread of infection.
  • You should keep up to date with immunisations.
  • You should use and dispose of sharps safely.
  • You should be aware of situations of increased concern, including patients with transmissible infections.
  • You should use routine infection control precautions, including decontaminating equipment that regularly comes into contact with patients.
  • You should know the measures to take in case of accident.
  • You must dispose of waste safely.

Introduction

B17
Infection control is concerned with two main areas. Firstly, transmission from person to person, and secondly, transmission via a contaminated object, such as an ophthalmic device or piece of equipment, or via contaminated contact lens solution bottles or multi-dose eye drops that have been used on another patient. In addition, there are environmental hazards that arise from your disposal of waste. 

Transmission from person to person

Routes for transmission

B18
There are four main routes for transmission, these are: 
  1. physical contact, which can spread:
    • ophthalmic infections, such as bacterial and adenoviral conjunctivitis
    • skin infections, for example staphylococcus, herpes simplex or fungi, and
    • enteric infections, for example viral gastroenteritis
  2. airborne particles, including respiratory infections, for example tuberculosis:
    • you are at a special risk of the transmission of airborne infection because of the proximity to the patient’s nose and mouth
    • potentially infectious respiratory aerosols are generated when an individual sneezes, coughs or talks. Particles over 5 microns in diameter do not normally travel more than 1m but smaller particles can travel longer distances and remain airborne for longer
  3. contact with bodily fluids:
    • you are at extremely low risk of transmitting blood borne viruses, such as human immunodeficiency virus (HIV) and hepatitis B and C, in optometric practice
    • tears can contain infectious agents (including these viruses, and others that are much more contagious such as adenovirus) which may be transmitted to yourself or to other patients if your hands are not properly cleaned after the clinical examination
  4. use of sharps: the main risk of transmission is associated with invasive procedures in which injury, for example needlestick, could result in blood from the infected individual entering open tissues of another person.
B19
You must use adequate infection control measures to avoid transmitting infections. 

Methods of preventing infection transmission from person to person

Hand hygiene

B20
You must decontaminate your hands regularly and thoroughly to prevent the spread of infection, see paras B30-B32.113  You can reduce the risk of transmitting infections such as meticillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile (C.diff) if you use fastidious hand hygiene.  
B21
There are a number of organisms present in healthy skin: some are resident organisms (skin commensals) and are mostly harmless, although some are known to cause mild eye infections. You can reduce the number of skin commensals left on your skin by washing with an antiseptic detergent preparation, instead of soap and water. 
B22
Other transient organisms can be deposited on the skin, including certain gram-negative bacteria which could lead to more serious corneal infections. You can remove most of these transient organisms by thoroughly washing with liquid soap and water. 
B23
You must decontaminate your hands, as appropriate: 
  1. before every episode of direct patient contact or care
  2. after every episode of direct patient contact or care
  3. after any exposure to body fluids (including tears)
  4. after any other activity or contact with a patient’s surroundings that could potentially result in hands becoming contaminated, and
  5. after removal of gloves.
B24
You can use an antibacterial handrub between patients during a clinic session. Alcohol is not a cleaning agent so you should perform a proper handwash with soap and water at the beginning and completion of the clinic session, as well as after exposure to body fluids. Alternatively, you can wash your hands between patients.  
B25
You should also decontaminate your hands:  
  1. before and after contact lens insertion or removal
  2. after going to the toilet
  3. when hands are visibly dirty
  4. before (and after) contact with ocular surfaces and adnexae
  5. before (and after, if necessary) administering medication, for example eye drops, and
  6. after any possible microbial contamination, e.g. contact with body fluids, wounds, or clinical waste.
B26
You should use the following handwashing technique for most procedures you perform in the clinical setting: 
  1. wet hands under running water
  2. dispense liquid soap or antiseptic into cupped hand (bar soap should not be used)
  3. rub hands vigorously and thoroughly for 10-15 seconds without adding more water
  4. ensure all surfaces of the hands are covered
  5. rinse hands thoroughly under warm running water, and
  6. dry hands with a disposable paper towel. You should not use non-disposable towels.

See  Annex 3 World Health Organization guidance on handrubbing and handwashing techniques.

B27
Hand hygiene agents include: 
  1. liquid soap
  2. antiseptic, and
  3. antibacterial (alcohol-based) handrubs.114 
B28
Handwashing with soap and water is effective in removing most transient microorganisms and is usually all you need to prevent cross infection. In clinical areas, you should: 
  1. use liquid soap in disposable containers or containers that are washed and dried before refilling, and
  2. never top up the containers.
B29
Antiseptic agents are effective in reducing both transient and resident microorganisms. Chlorhexidine (4%) preparations have a residual effect against transient organisms influencing the survival time on hand surfaces. You should use an antiseptic agent: 
  1. before and after direct contact with patients in clinical settings, where there is an outbreak of antimicrobial resistant organisms (e.g. residential or nursing homes)
  2. where there is heavy microbial contamination, or
  3. before performing invasive procedures or minor operations.
B30
Antibacterial (alcohol-based) handrubs rapidly destroy microorganisms on the skin surface. However, they are not a cleaning agent and you should not use them if hands are visibly dirty or contaminated with blood, bodily fluids or other potentially infectious agents. They are especially useful in situations where handwashing and drying facilities are inadequate e.g. domiciliary visits, or between patient contacts. 
B31
You should not use alcohol handrubs as a substitute for handwashing with soap and water, when these are available. You are strongly advised to wash your hands at the start and finish of a session. Alcohol handrubs are not effective against Clostridium difficile spores or norovirus (a cause of viral gastroenteritis) so you should use liquid soap and water in situations where there is potential for the spread of these organisms. 
B32
The standard for efficacy of hygienic handrubs uses a reference of 60% isopropyl alcohol. However, to be effective against staphylococci, including MRSA, handrubs must contain 70% of either ethyl or isopropyl alcohol. 
B33
If you use an unperfumed alcohol-based handrub prior to contact lens insertion it has been shown to have a negligible effect on ocular comfort, redness and lens wettability. You should ensure that the handrub has been allowed to dry on the hands as instructed by manufacturers (often 15 seconds). 

Maintain the integrity of your skin 

B34
To maintain the integrity of your skin, you should:
  1. cover cuts and abrasions to skin with waterproof dressings (preferably coloured)
  2. dry skin properly with paper hand towels after washing, and
  3. use hand cream as appropriate; you should not share jars of hand cream with others.

Keep up to date with immunisation

B35
You should keep up to date with immunisation, including: 
  1. tetanus
  2. polio
  3. tuberculosis, and
  4. hepatitis B. 

Minimise the risk of airborne infection

B36
You should minimise the risk of airborne infection by:115
  1. covering your nose and mouth and using a tissue whilst coughing or sneezing
  2. disposing of used tissues in the nearest receptacle as soon as possible116 
  3. performing hand hygiene after coughing or sneezing
  4. not working in clinical practice if you have an acute upper respiratory tract infection, such as the common cold, and
  5. avoiding touching your mouth, eyes and nose unless you have performed hand hygiene. 

Protective clothing

B37
Wear protective clothing:
  1. to protect against direct contact with body fluid, or
  2. while handling and cleaning decontaminated equipment. 

Masks

B38
You do not have to use a mask, unless there is a serious respiratory risk involved. Ordinary surgical masks are not effective protection. In these cases you should wear specialised respiratory protection.117 

Gloves

B39
You should wear gloves where you consider there is a risk from: 
  1. invasive procedures
  2. contact with:
    • non-intact skin, or
    • mucous membranes
  3. exposure to:
    • blood
    • bodily fluids, including tears
    • secretions
    • excretions
    • sharp or contaminated instruments, or
    • other contaminated material, for example dressings.
B40
You should consider the following factors when deciding to wear gloves: 
  1. whether the patient has an overt infection, such as ulcerative blepharitis or acute viral or bacterial conjunctivitis
  2. the degree of contact with bodily fluids or infected tissue, and
  3. the consequences of infection.
B41
You do not have to wear gloves to:
  1. carry out a normal eye examination
  2. perform minor procedures where there is no likelihood of cross-inoculation with bodily fluids, or
  3. fit contact lenses.
B42
You should practise thorough hand hygiene before wearing, and after removing, gloves, as they may not provide complete protection.
B43
You must dispose appropriately of gloves that you believe are contaminated.
B44
You can use non-sterile disposable examination gloves. However, if you undertake a procedure which requires a sterile environment you must use sterile surgical gloves. You must not use polythene gloves for clinical interventions. If you choose to use latex gloves you should be aware that these might cause allergic reactions such as asthma in sensitised individuals.118 119

Appropriate sharp disposal

B45
You should use and dispose of sharps safely by: 
  1. using equipment with safety devices, and
  2. using safe handling and disposal procedures.
B46
You must follow the NICE guidance on sharps containers.120 

Situations of increased concern - transmission from person to person

High-risk groups

B47
High-risk groups include those patients with MRSA, C.difficile, tuberculosis (within the first two weeks of treatment), or pandemic influenza (where there is no vaccine available) and Staphylococcus aureus have caused particular concern in recent times.
B48
Staphylococcus aureus is a bacterium that can reside on the skin, or can be found in the nose. About one third of healthy individuals carry S. aureus. MRSA is a less common variant of S. aureus which may be resistant to many antibiotics making it more difficult to treat than normal strains of the bacterium. MRSA may be a problem in many hospitals and, although the risk of serious infection with MRSA is lower in the community, it still exists and this organism is increasingly seen in community health care units, such as nursing homes. MRSA does not cross intact skin.
B49
There is little risk of infection for healthy clinical staff; however, infection control is important to avoid transmission to vulnerable people.

MRSA in the community

B50
MRSA detected in the community may be the result of:
  1. patients discharged from hospital with MRSA
  2. nursing home residents who have acquired MRSA
  3. MRSA transmitted to non-hospitalised patients or individuals from MRSA patients, or
  4. MRSA arising naturally in the community.
B51
If you examine a patient with a known transmissible infection, you should:
  1. increase the effectiveness of your hand hygiene by:
    • keeping nails short and clean and free of nail varnish and avoiding artificial nails
    • avoiding wearing jewellery, especially rings with ridges or stones, and
    • avoiding wearing wristwatches, and
  2. keep in mind NHS policy on clinician attire by:
    • wearing short sleeves or rolling up long sleeves, and
    • not wearing a tie.

Transmission via an inert agent

B52
Transmission via an inert agent can be from a contaminated object, such as an ophthalmic device or piece of equipment, or via contaminated contact lens solution bottles or multi-dose eye drops that have been used on another patient.

List of agents that may harbour infection

B53
The agents that may harbour infection are:
  1. contact lenses, contact lens cases and other paraphernalia
  2. ophthalmic devices such as:
    • tonometer heads
    • pachymeters, and
    • diagnostic lenses that come into contact with the ocular surface, such as: gonioscopes, fundus lenses, three-mirror lenses and lenses used in conjunction with laser therapy, and
  3. the environment: bacteria may contaminate flat surfaces if they become airborne. Bacteria that are shed into the environment may survive for long periods in dust. Flat surfaces act as reservoirs for S.aureus, including MRSA, and contamination will transfer easily to hands when such surfaces are touched. Contamination on hands and/or gloves may be similarly transferred by contact with equipment, switches, phones, computer keyboards, door handles, light switches etc.
B54
There is a remote theoretical risk, identified by the Department of Health (DH), of transmitting prion proteins, which are associated with transmissible spongiform encephalopathies (TSEs) and are implicated in Creutzfeldt Jakob Disease (CJD) and variant CJD (vCJD), through re-useable ophthalmic devices and trial contact lenses. However, there is no evidence that this has occurred,121 and this risk has been questioned.122 The anterior eye has been designated as low risk.121  The advice that follows reduces the potential risk of iatrogenic transmission of CJD/vCJD.

Methods of preventing infection transmission via an inert agent

B55
You should use the following routine infection control precautions:
  1. maintain good hand hygiene,113 see paras B20-B33
  2. decontaminate equipment after use, see paras B56-B80
  3. disinfect used linen, and
  4. decontaminate the environment:
    • keep it clean and free from dust, and
    • disinfect spills of body fluid.

Principles of cleaning, sterilisation and disinfection

B56
You should decontaminate equipment that regularly comes into contact with patients, including:
  1. trial frames
  2. chin rests
  3. refractor heads
  4. handheld occluders
  5. rulers
  6. tonometer heads
  7. gonioscopes and other diagnostic lenses, and
  8. contact lenses.
B57
You should decontaminate equipment in all situations where you or your patients are at risk of any known transmissible infection, including settings such as:
  1. nursing homes
  2. schools, or
  3. workplaces.
B58
There are three levels of decontamination. You should use the one that is most appropriate for the item being decontaminated. The three levels are:
  1. cleaning to remove organic or inorganic debris. This may be done with detergents or ultrasonic cleaning
  2. disinfecting to reduce viable microorganisms with heat or chemicals, or
  3. sterilising to kill or remove all microorganisms, including spores. This is not normally required in optometric practice.
B59
You must clean the items first.
B60
Not all equipment needs to be sterile before being used and you should:
  1. clean equipment which does not come into close contact with mucous membranes or sterile body areas, e.g. trial frames and refractor heads
  2. clean surfaces in the consulting room, unless contaminated with body fluids, see d below
  3. disinfect equipment which comes into close contact with intact mucous membranes
  4. disinfect surfaces in the consulting room if contaminated with body fluids, using a chlorine-releasing disinfectant such as sodium hypochlorite 1% (10,000 ppm of available chlorine), and
  5. sterilise equipment introduced into a sterile body area or in contact with a break in the skin or mucous membrane.
B61
You should have access to a hand basin in, or near, the consulting room.

Levels of decontamination

B62
Agents recommended for cleaning and disinfection procedures:
AgentPreparationExamples of use
Liquid soap as supplied handwash
Chlorhexidine gluconate 4% skin cleanser 500 ml bottles with pump dispenser e.g. Hibiscrub antiseptic handwash
Chlorhexidine 5% in 70% isopropyl alcohol
500 ml bottles with pump dispenser e.g. Hibisol
antiseptic hand disinfectant for use before aseptic procedures or after handling contaminated materials
Alcohol-based hand sanitizer as supplied, usually in bottles with pump dispenser e.g. Purell (contains 63% ethyl alcohol) routine handrub
Detergent general purpose detergent

detergent impregnated wipes e.g. Cutan multisurface wipes
leaning of hard surfaces
Isopropyl alcohol 70%123 impregnated swabs
e.g. mediswabs or wipes
e.g. mediwipes
disinfection of hard surfaces, chin rests etc.
(not suitable for use with medical devices that come into contact with the surface of the eye)
Hypochlorite solution 0.1%
(1,000 ppm available chlorine)
available from pharmacies e.g. Milton or own brand sterilising solution (dilute to concentration required)

under normal usage, these agents are disinfectants, and not sterilants
general disinfection
(ensure that items are thoroughly rinsed in sterile saline or distilled water after using hypochlorite)
Hypochlorite solution 1%
(10,000 ppm available
chlorine)
disinfection of body fluid spills and decontamination of trial contact lenses, diagnostic contact lenses, tonometer heads and other devices that come into contact with the surface of the eye (ensure that items are thoroughly rinsed in sterile saline or distilled water after using hypochlorite)
B63
Items must be clean before progressing to disinfection or sterilisation.

References

123 Coia JE, Duckworth GJ, Edwards DI et al (2006) Guidelines for the control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection 63 Suppl 1:S1-44 

The re-use of contact lenses and ophthalmic devices

B64
You should use single patient use lenses and devices contacting the surface of the eye where practicable.
B65
You should not re-use a lens or device that is intended for single use by the manufacturer.
B66
When single use lenses and devices are not practicable, you should:
  1. balance the benefits that patients receive from contact lenses and ophthalmic devices against the transmission of disease, and
  2. apply decontamination procedures which include the use of sodium hypochlorite solution where possible, see para B62.122
B67
See para B54 above regarding the risks relating to Creutzfeldt Jakob Disease (CJD) and variant CJD (vCJD), and re-useable ophthalmic devices and trial contact lenses.

Definitions of contact lenses

B68
You should note these definitions of contact lenses:
  1. trial contact lens: a lens that is used to assess fitting following which it is either disposed of by the clinician or dispensed to the patient. Currently the majority of contact lens patients are fitted with single patient use lenses of various types
  2. special complex lens: a lens used by the clinician to assess performance of the design on the eye, which may be necessary where there is disease or abnormality of the lid, cornea or ocular surface. These lenses may be re-used.
B69
The above definitions can apply to the following categories of lenses:
  1. hydrogel lenses
  2. silicone hydrogel lenses
  3. hybrid lenses, and
  4. rigid lenses, including:
    • corneal
    • sclera
    • scleral shells, and
    • ocular prostheses.
B70
Special complex lenses may be of any type. If you use these lenses you should:
  1. use them only within your premises and they must be under your control or that of another clinician at all times
  2. carry out appropriate decontamination
  3. keep full records to show the usage of each lens, and
  4. inform the patient of the risks and benefits associated with contact lens fitting. See section on Fitting contact lenses.

Definitions of ophthalmic devices

B71
An ophthalmic device is any instrument which comes into contact with the ocular surface, including:
  1. tonometer
  2. contact pachymeter
  3. gonioscope, or
  4. other lens to aid diagnosis of disease.
B72
Where it is practicable you should use single use devices, such as disposable tonometer heads or tips.
B73
Some devices are not able to withstand decontamination: in these cases you should use your professional judgement, bearing in mind that undetected disease may have sight- or life-threatening consequences.
B74
You must explain to the patient the risks and benefits of re-using a device.

 

How to decontaminate

B75
You should not use alcohol wipes alone to decontaminate contact devices as they are ineffective against many organisms, and may fix prion proteins to the surface of the instrument.122
B76
Prion proteins adhere strongly to materials including smooth surfaces. You should ensure that the device is thoroughly cleaned to remove adhered debris as the potential for the transmission of cellular and proteinaceous debris via tonometer prisms has been demonstrated.124 125
B77
You must not use agents or procedures capable of binding proteins to surfaces e.g. isopropyl alcohol, glutaraldehyde or autoclaving, unless you decontaminate devices first, following the process outlined in para B80
B78
You should use 1% sodium hypochlorite solution to decontaminate. The concentration advised has been reduced to a level which is:121
  1. appropriate for inactivating infectious agents such as bacteria and viruses, and
  2. less harmful to the eye than stronger concentrations if it accidentally comes into contact with it.
B79
You need the following equipment for decontamination of contact lenses or ophthalmic devices:
  1. water for irrigation BP, or sterile normal saline
  2. cleaning solution, such as liquid soap or detergent, and
  3. sodium hypochlorite solution 1% (10,000 ppm of available chlorine).
B80
You must follow this process to decontaminate contact lenses or an ophthalmic device:

StepACDP TSE WG, 2011 recommendation121Notes
When to decontaminate immediately after use immediately decontaminate the item, and if this is not possible, keep it in a container of water for irrigation BP or sterile normal saline, until it can be decontaminated.
Do not dry do not allow to dry  
Rinse in water for irrigation BP/sterile normal saline for at least 30 sec  
Clean rubbing with liquid soap or detergent thoroughly clean the item (including by rubbing) to remove cellular debris and adherent protein
Decontaminate using sodium hypochlorite
1% (10,000 ppm of available chlorine) for 10 min

decontaminate it by using sodium hypochlorite
Rinse in water for irrigation BP/sterile normal saline for at least 10 min with 3 changes of water/saline thoroughly rinse off the sodium hypochlorite, which is toxic to the eye, before re-use
Dry shake off excess, dry with tissue, re-use immediately or store dry return the item to its dedicated case, if it has one
Further steps if necessary, since hypochlorite is not effective against all spores or cysts follow with conventional disinfection

References

121 Managing CJD/vCJD risk in ophthalmology Annex L (2011) In: Department of Health. Advisory Committee on Dangerous Pathogens Transmissible Spongiform Encephalopathy (ACDP TSE) Risk Management Subgroup (2011) Guidance on prevention of CJD and vCJD [accessed 18 Dec 2013]
122 Buckley R (2010) Decontamination. Optometry in Practice 11(1), 25-29
124 For cellular debris: Lim R, Dhillon B, Kurian KM et al (2003) Retention of corneal epithelial cells following Goldmann tonometry: implications for CJD risk British Journal of Ophthalmology 87(5), 583-586
125 For proteinaceous debris: Amin SZ, Smith L, Luthert PJ et al (2003) Minimising the risk of prion transmission by contact tonometry. British Journal of Ophthalmology 87(11), 1360-1362

Measures to take in case of accident

B81
Chlorine can be toxic to the eye, but if you follow the decontamination guidelines correctly there is no situation in which sodium hypochlorite solution comes into contact with a patient’s eye. However, if this does occur, you should follow this process:
  1. irrigate the affected eye immediately with copious quantities of sterile normal saline solution or water
  2. check the ocular surface for epithelial damage using fluorescein
  3. examine the anterior segment for inflammation
  4. check intraocular pressure
  5. if there are no clinically significant signs, advise the patient to re-attend the practice if they experience any problems with their eyes, otherwise you should re-examine them at the normal interval
  6. if there are clinically significant signs, you should re-examine the patient the following day or refer them to the Hospital Eye Service, as appropriate
  7. record any adverse incident centrally, in your practice’s system or in the practice Accident Book, and
  8. if you feel it is appropriate, report the incident to the National Reporting and Learning System which is anonymous and helps lessons to be learnt from adverse incidents.126

Storage and handling

B82
You are not required to label sodium hypochlorite 1% solution as harmful or irritant under the COSHH regulations.127 You should follow appropriate measures for safe storage, access and handling.

Contamination via contact lens solutions and medicine bottles

B83
You should carefully maintain all contact lens care products and medicines used during examination and discard any prior to their expiry date.
B84
You should:
  1. be aware that multi-dose containers can be a source of cross infection
  2. be aware that varying levels of contamination exist in plastic bottles containing contact lens solutions, and
  3. note when these bottles are opened and discard them according to manufacturer’s guidelines, which vary depending on the product and its use.
B85
You should:
  1. keep the dropper tip free from contamination
  2. replace the lid on the container immediately after use as all solutions are susceptible to contamination during the time that caps are removed, and
  3. dispose of solutions immediately if you suspect contamination.
B86
Use single use drug delivery systems, where possible.

Situations of increased concern - transmission via a contaminated object

High-risk groups

B87
Patient groups that have been identified as being at greater than normal risk of developing transmissible spongiform encephalopathies (TSE) include:121
  1. patients with a history of CJD or other prion disease in the family
  2. recipients of pituitary derived hormones such as human growth hormone or gonadotrophins
  3. patients who have had surgery on the brain or spinal cord, or
  4. patients who have, since 1980, received more than 50 units of blood or have received blood or blood components on more than 20 occasions.

Examining a patient in a high-risk group

B88
Before carrying out any procedure that might involve the re-use of a contact lens or ophthalmic device you should, as far as possible, question the patient to establish if they fall into any of the above high-risk groups. If the patient is in a high-risk group you must only use items intended for single patient use. If this is not possible you should consider referring the patient to the Hospital Eye Service.
B89
If you use a re-usable item in an emergency with a patient in one of the above high-risk groups you should discard it immediately after use.
B90
If you examine a patient with a known transmissible infection, you should:
  1. cover cuts and abrasions to skin with waterproof dressings (preferably coloured)113 
  2. carry out hand hygiene before and after each patient contact and before and after leaving their home or care home, see paras B20-B33 above, and
  3. follow the guidance in paras B51 a and B51 b above.

Safe disposal of waste

B91
You must take all reasonable steps to deal with controlled, clinical and offensive waste appropriately, including both non-hazardous and hazardous waste.128 129 130 131 
B92
Controlled waste is defined as waste from households, industry or commerce.
B93
Clinical waste means waste from a healthcare activity¸ and waste of a similar nature from a non-healthcare activity, that:132
  1. contains viable microorganisms or their toxins which are known or reliably believed to cause disease in humans or other living organisms
  2. contains or is contaminated with a medicine that contains a biologically active pharmaceutical agent, or
  3. is a sharp, or a body fluid or other biological material (including human and animal tissue) containing or contaminated with a dangerous substance within the meaning of Council Directive 67/548/EEC on the approximation of laws, regulations and administrative provisions relating to the classification, packaging and labelling of dangerous substances.
B94
Offensive waste means waste that:133
  1. is not clinical waste
  2. contains body fluids, secretions or excretions, and
  3. falls within code 18 01 04, 18 02 03 or 20 01 99 in Schedule 1 to -
    • the List of Wastes (England) Regulations 2005, in relation to England,134  or
    • the List of Wastes (Wales) Regulations 2005, in relation to Wales.135
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