Contradictory guidelines from the CDC, the World Health Organization, and the U.S. Department of Transportation on how to handle the medical waste of Ebola patients are raising questions for U.S. hospitals.
No surprise.
News out of Dallas this week of the first patient diagnosed with Ebola raises many practical questions about how healthcare providers should handle additional cases in the United States stemming from the largest Ebola epidemic in the world.
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Imagine you're an emergency department or other hospital worker at Texas Health Presbyterian Hospital. How confident would you be feeling right now, with the head of the National Institutes of Health telling the world that one or more people on your team "dropped the ball," and with news that some 100 people are now being monitored because of potential exposure?
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Many questions about proper procedures and precautions—to prevent such an infection control lapse occurring again—are still unanswered:
1. How should hospitals handle bed linens and towels that may be contaminated with viral particles? Most hospitals contract with medical waste laundry services that clean soiled linens offsite.
The Centers for Disease Control and Prevention's Ebola page, updated Aug. 1, has two answers:
- "… discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains as a regulated medical waste."
- "…materials should be placed in leak-proof containment and discarded as regulated medical waste. To minimize contamination of the exterior of the waste bag, place this bag in a rigid waste receptacle designed for this use. Incineration as a waste treatment process is effective in eliminating viral infectivity and provides waste minimization. However, check with your state's regulated medical waste program for more guidance and coordinate your waste management activities for the patient's isolation area with your medical waste contractor."
But what should hospitals do with such materials for other patients? And what are laundry processing companies doing to assure that their workers are not infected while handling infected materials?
2. How should toilet waste from suspected Ebola patients be disposed?
At Nebraska Medical Center, where Rick Sacra, MD, a Massachusetts physician infected with Ebola while working in a Liberian hospital last month, toilet wastes were treated with a disinfectant in the toilet for 10 minutes before being flushed into the sewer treatment system according to an article in the Nebraska World-Herald. The CDC, however, says human wastes can be flushed with no treatment.
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3. Should all hospitals treating Ebola patients have on-site sanitizers?
Darrell Henry, executive director for the Healthcare Coalition for Emergency Preparedness, which receives 50% of its financial support from manufacturers of on-site medical waste sterilization systems, believes that major hospitals such as teaching hospitals and trauma centers should have these facilities, but far too many do not.
Henry says that 2,500 of the 3,500 non-critical access hospitals in the country do not have such systems, including one-third of the hospitals in California. Texas Health, he said, does not.
Asked if that is true, Laura Van Hoosier, a spokeswoman for Texas Health, replied: "We are coordinating all of our efforts with CDC on how we handle Ebola waste. At this time we are containing and securing all of the Ebola waste that we currently have and will continue to do so until CDC advises us otherwise."
Henry points to industry confusion and concern because of three contradictory policies issued by three organizations, the CDC, the World Health Organization, and the U.S. Department of Transportation, on how Ebola waste should be categorized and discarded.
The WHO recommends that highly infectious waste should be sterilized immediately by an autoclave device, whereas the CDC says they should be placed in level-four pathogen bio-safety containment and treated as regulated medical waste.
Regulations from the Department of Transportation "make it nearly impossible for such waste, in volumes produced by an infected patient(s), to be shipped," says HCEP.
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In letters to Texas state and federal emergency preparedness officials, Henry said his coalition thinks on-site autoclaving facilities should be required, but which the CDC stops short of recommending. The systems can cost between $500,000 to $1 million each, or less for smaller units, but save 25% per pound of waste on disposal costs compared with a delivery service, he said.
4. Hospital officials should educate all staff how to properly screen patients for Ebola symptoms and risk. But if one slips through, as apparently happened in Dallas, should that provider be disciplined or fired?
On Wednesday, Texas Health's executive vice president Mark Lester, MD, confirmed that the Ebola patient, Thomas Eric Duncan told an emergency department nurse during his first visit Sept. 26 that he had recently been in West Africa. "Regrettably, "Lester said, "that information was not fully communicated throughout the whole team."
I asked Albert Wu, MD, director of the Center for Health Services and Outcomes Research at Johns Hopkins and an expert on healthcare worker trauma and grief, how Texas Health should handle that lapse.
"If the nurse failed to communicate appropriately, this is a problem that is highly likely to be repeated both at the specific ED and by many other providers," Wu said. "So discipline seems silly and ineffective. Guidance, protocols and staff education seems like what would be called for."
On Sept. 26 Duncan was given antibiotics and sent home, undiagnosed.
No additional cases have been reported yet, but in an interview with a broadcast reporter on Wednesday, Dallas County Health Director Zackary Thompson said, "there may be another case that is a close associate with this particular patient."
As of Thursday morning, Dallas County Health and Human Services reports that number of people who had possible contact with Duncan in Dallas has risen to up to 100, according to the Wall Street Journal.
5. What is ZMapp and why isn't there any more of it for healthcare workers, who are at greatest risk of infection from treating people with Ebola?
ZMapp is currently an experimental drug to treat symptoms of Ebola, but it is has not yet been tested for safety or effectiveness. It was given to several international aid workers fighting Ebola in West Africa, including two Americans, but its effectiveness is unclear.
In any case, Texas Health epidemiologist Edward Goodman, MD, and the CDC say that supplies have run out. The manufacturer is said to be gearing up production.
6. Should the U.S. and foreign nations further tighten, restrict, or place a moratorium on travel into the U.S. from West Africa?
At airports in West Africa, international travelers are being screened for fever with infrared thermometers that can read temperatures non-invasively. Those that don't have a temperature may board, since people who have no symptoms of viral disease are not infectious.
But Dallas County Health Director Zackary Thompson thinks world leaders should consider more aggressive prevention strategies.
"I think it should be reassessed," he told a reporter during a broadcast interview Wednesday. "The bottom line is we really need to look at individuals who are entering this country from those endemic areas where the Ebola outbreak is going on. There has to be a period of time, 2–21 days that we really need to look at them not entering until they are assessed by medical professionals to determine that they're not contagious. That's the issue, but right now that's not in place.
7. In the United States, what percentage of people infected with Ebola will die?
In the 33 previous outbreaks of Ebola virus since the first one in 1976, most in West Africa fatality rates have ranged from zero to 100%, with an average of 67%.
The fatality rate in the U.S., where patients presumably receive more rapid and sophisticated medical attention, is anyone's guess. But it will likely be a lot lower.