Disposal of Ebola Waste in US Hospitals

Ebola generates a lot of medical waste. From the protective gear medical personnel wear to the towels and sheets that clean up vomit, blood, urine, and feces from infected patients, Ebola isolation wards can go through a large amount of material. While treating the first US Ebola patients, Kent Brantley and Nancy Writbol, Emory University Hospital was going through up to 40 bags a day of medical waste.[1] Normally medical waste is disposed of carefully but easily as the material either isn’t infectious or carries a disease that pose a minimal threat to others. Ebola is different in that the soiled materials are very infectious and the disease is a serious one with devastating consequences should it end up spreading widely. Under favorable conditions the virus can remain infectious on solid surfaces for several days.[2] We generally trust that our hospitals know what they’re doing when handling medical waste (though MRSA and other resistant bacteria strains started and spread in hospitals). When it comes to Ebola, however, even the hospitals are at a loss as to how to dispose of it.

Under the U.S. Department of Transportation (DOT’s) Hazardous Materials Regulations[3] the company had a point: Ebola is classified as a Category A infectious substance and its handling and disposal are strictly regulated.[4] A Category A material is “a material known or reasonably expected to contain a pathogen, such as Ebola, that is in a form capable of causing permanent disability or life threatening or fatal disease in otherwise healthy humans or animals when exposed to it.”[5]

Emory University Hospital ran into this problem while treating US Ebola patients.[6] Stericycle, the company that manages disposal of their medical waste refused to handle the Ebola material,[7] citing federal regulations that prohibited their handling.[8] Ebola waste, like all Category A waste, must be disposed by trained personnel[9] in strictly defined packaging.[10] Luckily for Emory, it was able to borrow a large autoclave from its university and use that to sterilize the waste prior to its ultimate disposal.[11] Many hospitals don’t have the isolation beds that Emory has, and very few can simply borrow an autoclave.[12]

The bodies of deceased Ebola patients pose another waste disposal problem[13] as they are still quite infectious and the handling of bodies must also be carefully managed by trained personnel.[14] Anyone handling the body should be dressed in personal protective equipment (PPE) just as if the patient was still alive.[15] The body should be covered in a plastic shroud that keeps the virus from touching the outside, then placed in a leak-proof bag at least 150 µm thick, then the entire bag must be cleaned of any residue and disinfected.[16] At the mortuary the body may not be removed from the bags and must be either cremated or placed in a hermetically sealed casket by workers wearing PPE.[17] All of this transport must also be coordinated with the local and state authorities, and the CDC must be consulted if any interstate transport is required.[18] So even handling the bodies of deceased patients generates waste in the form of PPE and requires that the individuals at every step of the process be trained in safe handling of Ebola. This could be a challenge, especially if the number of trained workers is stretched thin.

The CDC recommends that disposable Ebola waste be “placed in leak-proof containment and discarded as regulated medical waste.”[19] However, “regulated medical waste” is regulated differently and subject to less stringent controls.[20] Hospitals, the CDC, and the DOT are working to resolve the issue of waste material disposal.[21] The DOT has said that the CDC and the DOT will likely give reexamined guidance next week.[22] Until the federal regulatory agencies responsible for regulation come to a consensus, hospitals are left in the breech, and the Texas Health Presbyterian Hospital in Dallas will have to be creative in coming up with ways to safely contain the Ebola waste materials until a solution can be coordinated.

Sources are below the cut.

[1] Dan Diamond, Ebola in America: One Hospital Just Treated Three Ebola Patients – And Already Cured Two of Them; http://www.forbes.com/sites/dandiamond/2014/10/01/ebola-in-america-one-hospital-has-already-treated-three-ebola-patients-and-cured-two-of-them/

[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] HMR; 49 C.F.R., Parts 171-180

[4]PHMSA Provides Guidance for Transporting Ebola Contaminated Items; http://phmsa.dot.gov/portal/site/PHMSA/menuitem.6f23687cf7b00b0f22e4c6962d9c8789/?vgnextoid=4d1800e36b978410VgnVCM100000d2c97898RCRD&vgnextchannel=d248724dd7d6c010VgnVCM10000080e8a8c0RCRD&vgnextfmt=print

[5] Id. (emphasis in the original)

[6] Hannah Bloch, Caring For The American Ebola Patients: Inside Emory’s Isolation Unit; http://www.npr.org/blogs/goatsandsoda/2014/08/18/340444100/caring-for-the-american-ebola-patients-inside-emorys-isolation-unit

[7] U.S. Hospitals Face Risks in Ebola Virus Waste Disposal; http://www.insurancejournal.com/news/national/2014/09/29/341846.htm

[8] PHMSA Provides Guidance for Transporting Ebola Contaminated Items, supra at 4.

[9] HMR; 49 C.F.R. § 172.704; http://www.law.cornell.edu/cfr/text/49/172.704

[10] HMR; 49 C.F.R. § 173.196; http://www.law.cornell.edu/cfr/text/49/173.196

[11] Ebola in America, supra at 1.