In my previous article on Ebola waste I discussed some of the problems and conflicting regulations regarding Ebola waste.[1] In this post I want to address some of the other concerns that have come to light regarding waste disposal since then. Ebola has reached areas of the US not under the strict control of the CDC or the NIH (e.g., the infected nurses’ apartments), arousing concerns about the disposal of waste in normal situations and regular hospitals; there is also a new ground for regulation conflicts as private companies are being asked to clean and dispose of Ebola waste as well as transport Ebola patients; the question of what happens to Ebola waste if it is flushed down a toilet is now being asked; finally, there are questions about the final resting place of contaminated items once they have been deemed safe.
Research on the infectivity of Ebola after it has left the body is scarce. Since research had to either be conducted in the field during active, unpredictable outbreaks or with the strictest of safety measures in a laboratory setting, few studies exist to address the questions we have now: how long does Ebola stay infectious in blood; how long does it stay infectious on surfaces; and how can Ebola be successfully removed from surfaces and materials without infecting others.[2]
One laboratory study found that Ebola will survive just as well on glass, rubber, or metal surfaces, all other things being equal.[3] The study was done in the dark, it was found that in favorable conditions the virus can survive for hours dried on to a surface outside of its host.[4] An additional study exposed Ebola virus, dried on to glass, to germicidal UV.[5] With an exposure time of 30 seconds, 90% of Ebola virons were inactivated, though this time could increase if in a protein-rich medium. The author suggests that even though 90% were inactivated, the large numbers of virons in the environment of an Ebola patient could make this 90% not as beneficial as it might seem at first.[6] Another study found that there was little risk of transmission from fomites (surfaces) in an isolation ward, as long as recommended infection control guidelines are adhered to.[7] Because of the scanty data, and because Ebola requires a very low dose to be infectious, the CDC recommends the autoclaving or incineration for Ebola infected materials.[8]
Once waste has been autoclaved or incinerated, the DOT no longer considers the material Category A infectious material but treats it like any other routine medical waste.[9] Other than autoclaves, no other method of disinfection has been standardized and would need to take into consideration worker safety issues as well as any state or federal safety regulations that might exist.[10]
Unlike Emory University Hospital, most hospitals do not have ready access to an autoclave to disinfect contaminated waste materials or incinerators to burn them.[11] To help guide hospitals, the CDC has issued “Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus.”[12]
None of our transportation or medical waste disposal guidelines were made with Ebola in mind. When the wastes were moved from Texas Health Presbyterian Hospital in Dallas, the federal Department of Transportation had to issue special permits to get around current hazardous waste shipment regulations.[13] Someone requiring a special permit can apply for a variance (a legal exception) to Hazardous Material Regulations[14] if they can show that their proposed form of transportation is at least as safe as the recommendations, or if it is in the public interest to grant a permit, even if the safety level is not the same.[15] When transporting Eric Duncan’s belongings, USDOT allowed a variance when only Stericycle did the moving, when the waste was triple-bagged and either secured in two drums or in a 96 gallon cart tested and certified, and carried in trucks carrying written spill plans and drivers with protective equipment.[16][17]
The CDC maintains a website to help inform waste managers of the basic guidelines for disposal of waste.[18] The CDC also points out an EPA page where state guidelines regarding medical waste disposal are listed.[19] Unfortunately, state guidelines do not seem to generally consider highly infectious material such as that found in Ebola in their guidelines; this is an entirely new type of public health threat. Because of that it can be difficult to see if state guidelines are being properly met. In these uncharted waters and with the high stakes involved in getting it right, no company wants to be the first to face a suit regarding improper disposal. As determining exactly what “proper” disposal is remains a challenge at this point, transporters are justified in balking at handling medical waste.
The CDC is the main advisor and consultant on Ebola waste disposal, but it is the EPA, the DOT, and even OSHA that determine the regulations surrounding transport and disposal. The DOT has a four-page guide to preparing Ebola waste for disposal, and it specifies that all parts of the Federal Motor Carrier Safety Regulations (FMCSR) must be adhered to “as applicable.”[20] In short, the regulatory system is just now starting to catch up to the realities of Ebola containment, and until the regulations are harmonized across all government agencies will people treating and cleaning up after Ebola be sure that they are doing the right things.
If you get Ebola, it’s okay to go to the bathroom. Reports that the DeKalb County threatened to cut off sewage systems from Emory University Hospital if Ebola wastes were being disposed in it were false.[21] Urine and feces flushed down the toilet into a sanitary sewer (most in the US are and have been for a while) is treated the same as any other waste, but the treatment is designed to inactivate infectious substances.[22] Sewage it treated by methods such as anaerobic digestion and composting to eliminate the spread of disease.[23]
There was a good deal of squabbling over the ultimate resting place of waste materials from the Eric Duncan. The belongings of Eric Duncan were taken to University of Texas Medical Branch Galveston’s (UTMB Galveston) Port Arthur, Texas incineration.[24] The state of Texas has asked that UTMB handle the medical waste from the Presbyterian Hospital in Dallas and they have agreed.[25] A level 4 biosafety lab exists there where they have been researching Ebola and other infectious diseases – they are confident that they can handle the threat.[26] (Incidentally, UTMB – Galveston has also agreed to and is preparing for treating any new Ebola cases that may arise in Texas.[27])
After the safe incineration there was still the issue of where to put the ashes. At first, they were scheduled to go to a Louisiana hazardous-waste landfill.[28] Even though the ashes could not be seen as infectious even against the most rigorous standards, Louisiana Attorney General Buddy Caldwell sought a temporary restraining order to keep Duncan’s incinerated remains from crossing state lines.[29] The Chemical Waste Management, Inc. in west Louisiana was expected to receive the ashes.[30] District Judge Bob Downing issued the injunction, granting Attorney General Caldwell his restraining order.[31]
In granting the restraining order, Hon. Mr. Downing said “. . . it is absurd to transport potentially hazardous Ebola waste across state lines.”[32] He said that Texas contractors must apply for Louisiana permits and provide Louisiana officials with documentation showing that the ashes were no longer contagious.[33] While the remarks as to infectiousness seem ill-informed, the exhortation that contractors get the relevant Louisiana permits is very valid. However, as of this writing I have not been able to find where Duncan’s ashes finally went.
For now I’m not sure how hospitals, apartment buildings, or anyone else will end up handing disinfected Ebola waste, or how they would adhere to varying regulations in the progress. At least we know that autoclaving and incineration are answers to Ebola waste’s infectiousness, if not its ultimate disposal. Toilets seem safe to use. And at least there is active work towards fixing this regulatory haze Ebola waste seems to have wound up in. We don’t seem to have been ready when Ebola got here, but hopefully with more effective oversight and less regulatory dilemmas hospitals will be ready if it turns up again.
Sources below cut.
[1] Pandemic Ebola, Disposal of Waste in US Hospitals; http://pandemicebola.com/2014/10/02/disposal-of-ebola-waste-in-us-hospitals/
[2] CDC, Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus; http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html
[3] Jose-Luis Sagaripanti et al, Archives of Virology (2010), 2035, 2037, Persistence in darkness of virulent alphaviruses, Ebola virus, and Lassa virus deposited on solid surfaces; http://download.springer.com/static/pdf/148/art%253A10.1007%252Fs00705-010-0791-0.pdf?auth66=1413590545_ca169a36fa10930f50d4625d26f53cd6&ext=.pdf
[4] Id.
[5] Jose-Luis Sagaripanti et al, Archives of Virology (2011) 489, Sensitivity to ultraviolet radiation of Lassa, vaccinia, and Ebola viruses dried on surfaces; http://download.springer.com/static/pdf/815/art%253A10.1007%252Fs00705-010-0847-1.pdf?auth66=1413590861_958437356d85d50141d424ab803db05d&ext=.pdf
[6] Id.
[7] Daniel G. Bausch et al, The Journal of Infectious Diseases, Assessment of the Risk of Ebola Virus Transmission from Bodily Fluids and Fomites, (2007, Supplement Two), 196; http://jid.oxfordjournals.org/content/196/Supplement_2/S142.full
[8] CDC, Ebola Medical Waste Management; http://www.cdc.gov/vhf/ebola/hcp/medical-waste-management.html
[9] Id.
[10] Id.
[11] Michael Wines, New York Times, Waste From Ebola Poses Challenge to Hospitals; http://www.nytimes.com/2014/10/18/us/waste-from-ebola-poses-challenge-to-hospitals.html?_r=0
[12] CDC, Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus, supra note 2.
[13] Wines, Waste From Ebola Poses Challenge to Hospitals, supra note 5.
[14] 49 C.F.R. §§ 171-181.
[15] 49 C.F.R. § 107.105.
[16] US DOT Pipeline and Hazardous Materials Safety Administration (PHMSA), DOT-SP 16266 (The official grant of the variance); http://phmsa.dot.gov/pv_obj_cache/pv_obj_id_AF2B344DB6BFEF895FC804DACF8D89776B420100/filename/DOT_SP_16266_Stericycle.pdf
[17] US DOT, U.S. Department of Transportation Approves Special Permit for the Safe Transport of Ebola Infected Medical Waste for Disposal, October 3, 2014; http://www.dot.gov/briefing-room/us-department-transportation-approves-special-permit-safe-transport-ebola-infected
[18] CDC, Ebola Medical Waste Management, supra note 3.
[19] EPA, Where You Live – State Medical Waste Programs and Regulations; http://www.epa.gov/waste/nonhaz/industrial/medical/programs.htm#wy
[20] DOT PHMSA, DOT Guidance for Preparing Packages of Ebola Contaminated Waste for Transportation and Disposal; http://phmsa.dot.gov/pv_obj_cache/pv_obj_id_E7AFD0A1C5DBDDE54BCAAA0A80F9D6898FF50400/filename/suspected_ebola_patient_packaging_guidance_final.pdf
[21] Valerie Hoff, 11 Alive Atlanta, Reports of threats if Ebola waste goes into sewage system; http://www.11alive.com/story/news/local/emory/2014/10/14/ebola-sewage-system/17273453/
[22] CDC, Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus, supra note 2.
[23] Id.
[24] Wines, Waste From Ebola Poses Challenge to Hospitals, supra note 5.
[25] Scott Noll, KHOU 11 News, UTMB Galveston agrees to dispose of Ebola medical waste; http://www.khou.com/story/news/local/2014/10/16/utmb-asked-to-lead-fight-against-ebola/17364397/
[26] Id.
[27] Samantha Ptashkin, Phillip Mena, Click 2 Houston, UTMB prepares to treat patients with Ebola virus, destroy Ebola waste; http://www.click2houston.com/news/utmb-prepares-to-treat-patients-with-ebola-virus-destroy-ebola-waste/29176238
[28] The Associated Press, Ashes of Ebola victim’s belongings will be sent to Louisiana landfill; http://www.nola.com/health/index.ssf/2014/10/ashes_of_ebola_victims_belongi.html
[29] Diana Samuels, The Times-Picayune, State Attorney general wants to stop ashes of Ebola victim’s belongings from being brought to Louisiana; http://www.nola.com/politics/index.ssf/2014/10/louisiana_attorney_general_wan.html
[30] Id.
[31] Kurtis Lee, Nation Now, Judge blocks disposal of Ebola victim’s burned belongings in Louisiana; http://www.latimes.com/nation/nationnow/la-na-nn-ebola-patient-landfill-louisiana-20141013-story.html
[32] Id.
[33] Id.
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