Managing Ebola Virus Contaminated Medical Waste On behalf of the Nebraska Biocontainment Unit

John Lowe Ph.D. [email protected] Assistant Professor, Dept of Environmental Health Associate Director of Research, Nebraska Biocontainment Unit Director of Public Health Training and Exercise Programs, Center for Preparedness Ed.

Nebraska Biocontainment Unit • Housed within the University of Nebraska Medical Center (UNMC) campus in Omaha, Nebraska 627 licensed beds 25,000 inpatient admissions per year Level I trauma center National Cancer Institute designated cancer care

• The Nebraska Public Health Laboratory (level 3) is also located on-campus • Eppley airport and Offutt Air Force Base are both within 10 miles of the UNMC campus

Cases at Nebraska • 2 U.S. citizens infected with EBOV in Liberia • 72 hr notice of confirmed EBOV transport • Transferred by air ambulance to Omaha, NE 4 weeks apart

Biocontainment Unit Pass-through Autoclave Staff Exit

10 CC beds/5 rooms Air locked entrances HEPA filter exhaust >15 air exchanges/hr

Laboratory

Waste Holding

Staff Entry

Med Equip. Holding Pt. Rooms

EBOV Waste Regulations • Waste from confirmed EBOV patient is classified as Category A infectious substances. • “medical equipment, sharps, linens, and used health care products (such as soiled absorbent pads or dressings, kidney-shaped emesis pans, portable toilets, used Personal Protection Equipment (gowns, masks, gloves, goggles, face shields, respirators, booties, etc.) or byproducts of cleaning) contaminated or suspected of being contaminated” • Must meet Category A shipping standards

U.S. Department of Transportation Guidance for Transporting Ebola Contaminated Items, a Category A Infectious Substance Accessed September 15, 2014 U.S. Department of Transportation’s Hazardous Materials Regulations (HMR; 49 C.F.R., Parts 171-180)

Category A Exemptions • Corpses, remains, and anatomical parts transported for interment, cremation, or medical research at a college, hospital, or laboratory. • Laundry or medical equipment complying with OSHA bloodborne pathogens standard intended for use, cleaning or refurbishment. Does not apply to medical equipment being transported for disposal. • Material that has been treated to fully eliminate, neutralize, or inactivate the pathogen (e.g., through autoclave or incineration). • Requires validation of sterilization

U.S. Department of Transportation Guidance for Transporting Ebola Contaminated Items, a Category A Infectious Substance Accessed September 15, 2014 U.S. Department of Transportation’s Hazardous Materials Regulations (HMR; 49 C.F.R., Parts 171-180)

Lowe, J.J., Gibbs, S.G., Nguyen, J., Schwedhelm, S.S., Smith P.W. Nebraska Biocontainment Unit perspective on disposal of Ebola medical waste. American Journal of Infection Control. 2014; (30):1-2. In Press http://dx.doi.org/10.1016/j.ajic.2014.10.006

Waste Streams • Solid waste stream • Liquid waste • HCW linens • Patient Electronics

Waste Transport • Transported as Category B, • Labeled and tracked similar to Category A • Incinerated and ashes taken to landfill • ONE CATEGORY A INCITERATOR in the U.S. • ONE LANDFILL receiving ashes from INCITNERATED CATEGORY A WASTE • Significant costs associated with Category A disposal

Waste Handler PPE • Biocontainment Unit staff handle all waste processing: Nurses, Medical Technicians, & Industrial hygienists • 464.4 cu ft of solid waste per patient • 1,011 lbs per patient

Healthcare and Emergency Responder Organization Education Through Simulation. Personal Protective Equipment: Biological Level-C Doffing. Omaha: University of Nebraska Medical Center, 2010 Available at 2014. http://app1.unmc.edu/nursing/heroes/mpv.cfm?updateindex=53&src=yt Accessed October 29, 2014

UNMCheroes.org

Decontamination • Personal Items • currency, passport, cell phone, camera • Medical Devices • Vacant Unit

Considerations • Alternative on-site sterilization methods/validation for Category A exemption • Waste processing training, designation of staff, holding site • Validation of virus inactivation • Landscape of waste disposal sites and regulations – incineration facilities and landfills

Nebraska Biocontainment Unit Leadership Team Phillip Smith MD Director, Angela Hewlett MD, Shelly Schwedhelm RN, Elizabeth Beam RN, Kate Boulter RN, Shawn Gibbs PhD CIH, John Lowe PhD

Nebraska Biocontainment Unit Staff 23 RN, 6 RT, 4 CT, 11+ MD, 2 PhD

Supporting Departments

Infection Control, Clinical Technology, Nebraska Public Health Laboratory, Core Clinical Laboratory, Public Affairs, Environmental Services, University & Hospital Facilities, Facilities Planning, and many more

External Partners

U.S. Department of State, Stericycle, Omaha Fire EMS, State & County Public Health, Cardinal Health, Apple, Offutt AFB, Epply Airport and many many more

On behalf of the Nebraska Biocontainment Unit

Contact information: John Lowe Ph.D. [email protected]