By Jacie Volkman, MPH, CIC, and Jim Brunner, CHSP
Last year, the U.S. witnessed its first case of the Ebola virus disease (EVD). As healthcare workers and civilian volunteers returned from West Africa to the U.S., questions surrounding how to evaluate and address EVD-related risks quickly came into focus—ranging from public health exposure to clinical practices inside hospitals.
Protocols using readily available tools of the trade were developed to provide guidance to healthcare facilities in the face of a potential crisis. However, as we move past the anniversary of the first EVD case in the U.S., it’s important we reexamine waste treatment regulations and the options available when handling both solid waste and patient effluent (blood, body fluids, urine, vomitus, etc.).
Specifically, we must reassess the efficiency of protocols determined early on as well and identify ways we can adapt our baseline methods and tools to be more resilient in the future. Only by doing this will we ensure maximum patient and healthcare practitioner safety and reduce the risk of transmission of potential epidemics like EVD.
EVD’s primary symptoms include fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal plan and can involve hemorrhage.1 The disease is spread by contact of mucous membranes with blood and body fluids of an infected human or animal who is ill or has expired from the disease. This can occur through contact with contaminated objects such as needles, sharp instruments, or exposure to body fluids such as urine, saliva, sweat, feces, vomit, breast milk or semen.(1)
Because of how the disease is transmitted, hospitals and municipalities must determine how to manage the massive amounts of waste that are inherent with just a single ”suspect” EVD patient. Emory University judges that approximately 40 pounds of waste is generated per patient, per day.(2)
Adopting a Clear Model for Solid Sanitation
Due to the tendency of EVD to cause copious amounts of virus-filled vomitus and diarrhea, many routine patient care activities present opportunities for transmission of EVD. In fact, healthcare practitioner infection with Ebola virus has been measured to be between 2.5 percent and 12 percent of all EVD cases.(3)
This increased risk for healthcare worker exposure has presented a variety of challenges in the U.S. One in particular is how to address environmental clean-up that must take place during and after care.
Ebola is an enveloped virus, which are typically unstable on surfaces, in light and with regular disinfectants, meaning they are easily inactivated. For disinfection of areas possibly contaminated with Ebola, the Centers for Disease Control (CDC) currently recommends the use of an Environmental Protection Agency (EPA) registered disinfectant with a non-enveloped virus claim.(4) Non-enveloped viruses, such as norovirus, are more difficult to kill and require a stronger disinfectant than enveloped viruses.
However, for solid contaminated items, appropriate disposal is more involved. The University of Nebraska biocontainment unit was one of the very first to test their planning and preparedness practices. The chosen practice for this facility is to bring solid wastes, such as PPE and linens, out of the patient room through a pass-through chamber system and then process them in an autoclave. The materials are then contained properly as regulated medical waste, only because it has been effectively treated on site. The waste is then shipped to an appropriate incineration facility for further destruction per the local and state requirements in that area.(5)
Finances and age of facility may limit some hospital institutions ability to upgrade to this method, however , it has gained acceptance because it is robust and has proven acceptable to all entities involved in the disposal process—even those offsite and not directly affiliated with the hospital.
University of Nebraska’s process is an example of how to prepare for in advance of the next wave of infectious disease. Teams should begin laying that groundwork now, if not already in place.
Barriers to Liquid Disposal
Possibly the most contentious aspect of clean up and sanitation surrounding EVD is treatment and disposal of liquid effluent wastes. The EPA states that disposing of these wastes through normal means (toilets and drains) is safe and that sewer systems were designed to handle disease and viruses present in the waste water systems.(6,7) However, the EPA also creates a paradox by simultaneously making recommendations toward practices such as those followed by the University of Nebraska. This included pouring a volume of sodium hypochlorite into the toilet along with the waste and allow it to sit for 10 minutes prior to flushing.(5)
This is likely an attempt to ease apprehension of municipal workers and regulators who do not have the same level of familiarity and confidence with treating and handling EVD as they do with other contaminants regularly disposed of in similar ways, such as hepatitis, HIV and typhoid.
Of course, inherent in this process is the risk present to healthcare practitioners in any such disposal. Healthcare workers who are required to significantly handle the contaminated waste, may experience splash back during dumping and cleaning, and chance aerosolization of the contaminated waste during the rinsing and flushing process.
Like with solid wastes, new processes or equipment may be needed in order to better prepare for future, EVD-like threats.
Further still, there are limits to the current EPA guidelines that could be addressed by new technologies or processes. The care of U.S. patients has been limited to single patients only but we must consider what could happen if there are multiple patients housed in one or several facilities. Are current guidelines reasonably and reliably followed? What does viral loading do to treatment plants and the efficacy of disinfection that happens in modern healthcare facilities?
The practice of sending appropriately treated solid waste to landfills and liquid waste through sanitary sewers continues to draw questions from both public and private sector entities and environmental advocates. Studies have proven that the virus is inactivated at high temperatures,(5,8) but there are still questions regarding the disposal of waste into the sewage system.
Municipal workers in the waste water treatment plants are concerned about the efficacy and practice of disinfection that takes place in the hospital. While, solid waste workers at landfills are concerned about the level and viability of remaining materials that may be left after autoclave or even incineration.
No cases of Ebola have been recorded due to treated sewage, nonetheless, the high mortality of the disease and high risk associated with its transmission has created a level of uncertainty that prevails throughout the sewerage districts in the U.S. Although characteristics and inactivation of the virus have been widely studied and are well understood, recommendations are lacking and municipal sewerage districts have differing requirements across the nation on a local level.
So, while we have clear direction regarding cleaning and disinfection, as well as avoiding transmission of the disease during care, more guidance is needed regarding the waste that is produced during the care of an EVD patient.
Jacie Volkman, MPH, CIC is on the board of APIC; owns Safe Patient Surveys Inc, an infection prevention consulting company; and is a consultant for MEIKO, a disinfection appliance manufacturer. She also is the director of infection prevention at Mission Health System.
Jim Brunner, CHSP, is a consultant for Safe Patient Surveys, Inc. He is also the director of corporate safety and serves as the corporate safety officer at Mission Health System. Brunner attended the University of Findlay where he received a bachelors degree in rnvironmental safety and occupational health/industrial hygiene.
1. http://www.cdc.gov/vhf/ebola/about.html/. Retrieved Aug. 4, 2015.
2. OSHA. Safe Handling, Treatment, Transport and Disposal of Ebola-Contaminated Waste. OSHA fact sheet. November 2014. Accessed July 2015.
3. Suwantarat N, et al. Ebola Virus Disease.; Cleaning and disinfecting Healthcare Environments. Retrieved Aug. 4, 2015 from http://www.cdc.gov/vhf/ebola/healthcare-us/cleaning/index.html.
4. World Health Organization. (2014) WHO Interim Infection Prevention and Control Guidance of Patients with Suspected or Confirmed Filovirus Hemorrhagic Fever in Health-care Settings, with Focus on Ebola. Retrieved August 4, 2015 from http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/
5. Lowe JJ, Gibbs SG PhD, Schwedhelm S, Nguyen J, Smith PW. Nebraska Biocontainment Unit perspective on disposal of Ebola medical waste. Am J Infect Control. Oct. 16, 2016. Accessed July 26, 2015.
6. Fischer R, Judson S, Munster V. Ebola Virus Stability on Surfaces and in Fluids in Simulated Outbreak Environments. Emerg Infect Dis. Jul 2015; 21(7):1243-6.
7. Mitchell S and McCormick J. Physiochemical Inactivation of Lassa, Ebola and Marburg Viruses and Effect on Clinical Laboratory Analyses. Journal of Clinical Microbiology. Sept 1984; 20(3); 486-489.
8. Cook B, Cutts T, et al. Evaluating Environmental Persistence and Disinfection of the Ebola Virus Makona Variant. Viruses. April 2015; 7; 1975-1986.