Q. What Personal Protective Equipment (PPE), protocols should facilities use for healthcare workers treating Ebola patients?
A. The Centers for Disease Control and Prevention (CDC) has issued guidance on the PPE to be used for all healthcare workers working with Ebola patients. The guidance emphasizes both the importance of repeated training for these workers and administrative oversight to ensure compliance with established PPE protocols. With respect to administrative controls, the CDC recommends the following:
- Establish and implement triage protocols to effectively identify patients who may have Ebola and institute the precautions detailed in the CDC guidance.
- Designate individuals as site managers responsible for overseeing the implementation of precautions for healthcare workers and patient safety. At least one site manager should be on-site at all times in the location where the Ebola patient is being treated.
- Identify critical patient care functions and essential healthcare workers for care of Ebola patients, for collection of laboratory specimens, and for management of the environment and waste ahead of time.
- Ensure healthcare workers have been trained in all recommended protocols for safe care of Ebola patients before they enter the patient care area.
- Train healthcare workers on all PPE recommended in the facility’s protocols. Healthcare workers should practice donning and doffing procedures and must demonstrate during the training process competency through testing and assessment before caring for Ebola patients.
- Use trained observers to monitor for correct PPE use and adherence to protocols for donning and doffing PPE, and guide healthcare workers at each point of use using a checklist for every donning and doffing procedure.
- Document training of observers and healthcare workers for proficiency and competency in donning and doffing PPE, and in performing all necessary care-related duties while wearing PPE.
- Designate spaces so that PPE can be donned and doffed in separate areas.?
Q. How should human remains of Ebola patients be handled in U.S. hospitals and mortuaries?
A. The CDC has issued a guidance document regarding the safe handling of human remains of Ebola patients. In summary:
- The body should be wrapped in a plastic shroud at the site of death in a way that prevents contamination of the outside of the shroud.
- Intravenous lines or endotracheal tubes should be left in place, and the body should not be washed or cleaned.
- After wrapping, the body should be placed in a leak-proof plastic bag not less than 150 µm thick and zippered closed. The bagged body should then be placed in another leak-proof plastic bag not less than 150 µm thick and zippered closed before being transported to the morgue.
- Prior to transporting the body to the morgue, the surface of the corpse-containing body bags should be decontaminated by removing visible soil on the outer bag surface with EPA-registered disinfectants which can kill a wide range of viruses in accordance with the product’s label instructions. Disinfectant should then be reapplied to the entire bag surface and allowed to air dry. The CDC recommends using a disinfectant with an EPA label claim for a non-enveloped virus (such as norovirus or rotavirus), for disinfecting surfaces known or suspected to be contaminated with Ebola.
- PPE is not required for individuals driving or riding in a vehicle carrying human remains, provided drivers or riders will not be handling the remains of a someone with a suspected or confirmed case of Ebola, and the remains are safely contained and the body bag disinfected as described above.
- Once it reaches the mortuary, the body should not be embalmed.
- Without opening the body bags or removing the remains, the bagged bodies should be placed directly into a casket and hermetically sealed. Mortuary personnel should wear PPE when handling the bagged remains.
- If any fluids leak from the body bags, the area should be thoroughly cleaned and decontaminated with EPA-registered disinfectants that can kill a broad range of viruses in accordance with label instructions. The CDC recommends using a disinfectant with an EPA label claim for a non-enveloped virus (such as norovirus or rotavirus), for disinfecting surfaces known or suspected to be contaminated with Ebola. Reusable equipment should be cleaned and disinfected according to standard procedures.
- Remains should then be cremated or buried promptly in the hermetically sealed casket.
- No PPE is necessary when handling the cremated remains or the hermetically sealed, closed casket.
- Transport of Ebola-infected remains should be minimized and coordinated with relevant local and state authorities in advance.
- Interstate transport should be coordinated with the CDC by calling the Emergency Operations Center at 770-488-7100. If shipping of remains by air is necessary, the remains must be labeled as dangerous goods in accordance with DOT regulations (49 CFR § 173.196).
Q. How should medical waste generated from the care of Ebola patients, including personal protective equipment, be managed?
A. Medical waste generated in the care of patients with known or suspected Ebola is a Class A infectious waste subject to the requirements of existing federal and state regulations. The CDC emphasizes that strict compliance with existing standards is required. The CDC’s website provides additional details on medical waste management. While medical waste generated in the care of patients with known or suspected Ebola follows an existing and standard regulatory classification, public fear of Ebola could create significant complications for related waste disposal. For instance, the Attorney General of Louisiana has obtained a temporary restraining order to prevent the disposal of the ashes from the incineration of Thomas Eric Duncan’s personal belongings in the state.
Q. Can we use any chemicals we want to disinfect?
A. No. The Environmental Protection Agency (EPA) regulates the claims of labels on anti-microbial products. Many are approved for use by the general public and can be applied by anyone, but should be used as instructed on the label. Other anti-microbials, however, are labeled for use by licensed applicators only. Application by non-licensed personnel is a criminal offense, as is use of these products in a manner contrary to their labeling. There are currently no disinfectants with approved label claims for Ebola. The CDC recommends, however, using a disinfectant with an EPA label claim for a non-enveloped virus (such as norovirus or rotavirus) for disinfecting surfaces known or suspected to be contaminated with Ebola.
Q. Will any of the chemicals used to disinfect cause other environmental issues of which we should be aware?
A. Yes. Many of the anti-microbials approved for disinfection of non-enveloped viruses are corrosive, and must be handled accordingly. They may also cause problems for local wastewater treatment plants if used in sufficient quantities. For example, chlorine bleach is a common disinfectant used in Ebola decontamination processes. The addition of too much chlorine to the wastewater stream entering a local wastewater treatment plant could cause the plant to violate its Clean Water Act permit. Many hospitals are required by state and/or federal regulations to obtain State Indirect Discharge (SID) permits under the federal Clean Water Act or state law equivalents. Those SID permits frequently include limits on the amount of chlorine that can be discharged to the local sewer system. In addition, the Clean Water Act and most state implementing laws and regulations provide that sewer systems can discontinue service to any facility whose waste stream causes the system to violate its Clean Water Act permit. Any facility that anticipates discharging significantly more chlorine or other anti-microbial products than usual should notify the local wastewater treatment system in advance so that appropriate precautions can be taken.
Q. How should workers in non-healthcare settings clean surfaces that have come in contact with the Ebola virus?
A. The U.S. Occupational Health & Safety Administration (OSHA) recently posted a guidance document called Cleaning and Decontamination of Ebola on Surfaces to help protect workers in non-healthcare and non-laboratory settings from Ebola exposure. The guidance can be found at this link.
Q. Should workers who handle untreated sewage be worried about Ebola infection?
A. There is currently limited data on the fate and transport of Ebola in wastewater collection systems. The CDC recommends, however, that sanitary sewer systems be used for the disposal of patient waste. Consequently, the America Water Works Association, the Water Environment Federation, and other water industry organizations have requested guidance from both the EPA and the CDC regarding the risks and whether there are additional protective or treatment protocols to consider or implement. At the present time, no such guidance has been issued. The CDC has indicated, however, that it has prepared and is in the process of expediting review of an Interim Guidance for Workers Handling Untreated Sewage from Ebola Cases in the United States. That document, which will include guidance and protocols for workers who perform sewer maintenance, construction workers who repair or replace live sewers, plumbers, and workers who clean portable toilets, is expected by the end of October.