Lisa Young David Jansen. Public Health Always Working for a Safer and Healthier Washington

Transcription

1 Lisa Young David Jansen Public Health Always Working for a Safer and Healthier Washington

2 Radioactive waste, asbestos, execution chemicals, narcotics Straightforward, Yes? 2

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4 Subdivides into two situations In the clinical environment Outside of the clinical environment

5 Tightly Regulated Waste solutions applied in the clinical environment are not easily applied to the non-clinical environment

6 Pathogen Risk Groups Risk Group 1 Low individual and community risk Risk Group 2 Moderate individual risk; low community risk Risk Group 3 High individual risk; low community risk Risk Group 4 High individual risk; high community risk

7 Canadian Standards Canadian Council of Ministers of the Environment Guidelines for the Management of Biomedical Waste in Canada Canadian Standards Association Z Handling of Waste Materials in Healthcare Facilities and Veterinary Healthcare Facilities

8 Segregation of Waste Biomedical Cytotoxic Pharmaceutical Chemical Radioactive General Recyclable

9 Biomedical Waste Generated by Human or animal healthcare facilities Medical or veterinary research and teaching Healthcare teaching Clinical testing or research laboratory Facility involved in the production or testing of vaccines

10 What is biomedical waste? Human anatomical waste Animal waste Microbiology laboratory wastes Human blood and body fluid waste Consists of fluid blood and blood products Items saturated with blood Body fluids contaminated with blood Waste sharps

11 How Much Biomedical waste is there? Quantities are typically small Can fit within a medical autoclave Toilet wastes are flushed

12 Biomedical waste

13 Remote Station Challenges Waste disposal Biohazard waste collection from stations is challenging Often waste is left at a hospital Remote areas may not go to a hospital Certainly not for every call

14 Comparison Canada and UK Canada Anatomical waste - RED Placentas, human tissue, organs and body parts Fluid waste YELLOW Blood soaked Sharps YELLOW BIN General waste BLACK Everything else UK Clinical Waste Infectious waste ORANGE Infectious waste contaminated with chemicals YELLOW Sharps YELLOW BIN Offensive waste TIGER STRIPE Anatomical waste RED Household Waste - BLACK

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16 The patient became symptomatic at home A residence was contaminated A clean up contractor was difficult to find A waste disposal option was difficult to find Disposing of the waste from the processing step went to litigation The wastewater utility was concerned about hospital discharges

17 CDC, OSHA guidance was a little slow and focused on the medical environment Early guidance showed little understanding of the waste management world

18 Bedpan sewage spilled on medical worker in a protective suit, disinfect with bleach (WHO/CDC) Sewage on a collection system worker, no risk (?) Different sources saying different things (Universities, professional associations, other states)

19 Medical Facilities Those not prepared for Ebola waste Medical Transportation Transit (ferries, busses, trains, planes) Single Family Homes Apartments Hotels Schools

20 Liquid Waste (Wastewater) Collection Disposal Solid Waste Cleanup Disposal

21 Wastewater (Public Sector) Treatment Plant Really not a problem Collection System A potential worker safety issue

22 Emphasis on communication between medical practitioners and wastewater managers Keep it simple for the medical providers Defer non-essential sewer maintenance Pre-disinfect patient waste if necessary for essential maintenance

23 The Ebola virus is rapidly destroyed by exposure to disinfectants, sewage, and the wastewater treatment process. We ve identified measures you can take to protect employees who may be working in the sewage collection system that serves your facility. We recommend the following steps: 1. Add the work and after-hours phone numbers of your sewer utility provider to your emergency call list. 2. Discuss your procedures and communication plan with the sewer utility manager. Make sure hospital facility workers such as plumbers who work with wastewater have the same information. 3. Notify the sewer utility provider immediately if you start treating a suspected or confirmed Ebola patient. 4. The utility may direct you to pretreat Ebola patient waste in order to protect workers who enter the collection piping (sewers). A typical approach for this pretreatment is described below. When emptying a bedpan or disposing of other patient waste, add about ½ cup of household bleach or an alternative disinfectant such as a quaternary ammonia compound. Do not combine disinfectants. Add the disinfectant to the toilet and let stand for five minutes before flushing. If the patient s condition doesn t allow a five-minute hold, add additional disinfectant, up to one cup. Lab waste containing chemicals or blood should be disposed of using normal protocols for such waste. Any waste disposed through a sink or toilet should be treated with a small amount of disinfectant, but be careful about mixing disinfectants with other chemicals. 5. Solid wastes (gowns, towels, gloves, sharps, etc.) cannot be discarded into the sewer system. Those materials must be discarded though the hospital medical waste program for solid waste. 6. If the sewer utility requests information on the patient s prior locations, refer the question to the local health jurisdiction. 7. Periodically check the Washington Department of Health webpage for updated information.

24 Safe handling of possibly Ebola-contaminated wastewater when serving a medical facility The Ebola virus is rapidly destroyed by exposure to disinfectants, raw sewage, and the wastewater treatment process. Ebola in wastewater is not a greater threat than other pathogens that may be discharged from a hospital, and sewer workers dealing with a hospital wastewater should always wear appropriate personal protective equipment. However, worker concerns specific to this pathogen are understandable and Ebola exposure may be a particular concern if sewer workers are working immediately downstream of a hospital discharge. These are recommendations for employers of workers who must enter the sewer - collection system near a facility that is treating a suspected or confirmed Ebola patient. We recommend that you: 1. Ensure all medical facilities you serve have your 24/7 call number for utility notification purposes. 2. Contact the medical facility to learn about the wastewater disposal methods they ll be using. 3. If notified of an active case, the best option is to reschedule sewer collection work in the areas downstream of the medical facility for the duration of the Ebola patient treatment period. 4. If sewer work close to the hospital is unavoidable, you may choose to direct the hospital to disinfect prior to discharge during the time your employees are working in the sewers. 5. Review your bloodborne/waterborne pathogen program with your employees and contact Washington State Department of Labor and Industries if you have questions. 6. If you need information on the patient s prior locations, contact your local health jurisdiction. 7. Share the Washington Department of Health s recommended guidance for medical professionals and clinics with your local medical community. 8. Periodically check the Department of Health Ebola webpage for updated information.

25 Medical autoclaves are not big enough for household waste (sofa, mattress, carpet) Industrial autoclaves and incinerators did not have feed systems capable of managing non-clinical contaminated waste Solid wastes must also be transported to the disposal site before autoclaving or incineration

26 Solid Waste Stericycle Morton (Private) Waste Management Industries Seattle (Private) Portable autoclave City of Spokane Incinerator (Public) Roosevelt Landfill (Private) Clean Harbors RCRA Incinerator, Utah (Private)

27 Feed System Concerns Systems not set up for careful feeding Shredding not a good solution for larger items

28 Worker safety concerns Neighborhood concerns Issues of timing (why invest in improvements before an event?) The public sector facility did not want this waste The private sector was more willing, but needed public leadership and investment return

29 Relatively similar in the Canada and the US

30 Ebola Transport of Dangerous Goods Regulations Ebola Category A Infectious Substance affecting humans UN2814 Type of container Watertight primary receptacle Watertight secondary packaging Absorbent material Outer packaging labelling

31 BC Ebola Waste 2 red waste sacks Secured individually at the neck by ties In a blue drum Leak-proof Puncture resistant Process of decontamination for collection

32 US-DOT Transportation Permit Ebola considered a Category A infectious waste Permit is required, but time limited and site specific, could not be pre-issued

33 What is a Category A infectious substance? A Category A infectious substance 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. An infectious substance classification is based on the patient or animal s known medical history or symptoms, endemic local conditions, or professional judgment concerning the individual circumstances of the source human or animal.

34 Because of the hazards posed by Category A infectious substances, these materials have more stringent packaging requirements and are not included in the definition of a regulated medical waste. Packaging requirements similar to British Columbia

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36 Set up an on-call contract with a biological clean-up firm Set up a quarantine facility For people And for pets Dealt with legal issues Access to properties Septic systems Damages from the cleanup Cost recovery through insurance

37 Confirmed that we had outlets for disposing of both clinical and non-clinical solid waste Contacted every wastewater system and sent them a link to our guidance 37

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39 Understanding the waste disposal industry is critical to properly disposing of biologically contaminated waste. The private sector and public works sector are essential partners in managing the waste streams

40 Motivated by Profit Risk Avoidance (political and monetary) Customer Service

41 Concerned with Employee Safety Risk Avoidance (political and monetary) Customer Service

42 We are setting up additional on-call contracts for clean-up contractors We are working with environmental regulators to help manage their requirements We are evaluating the solid waste disposal systems We have improved our communication systems with the wastewater community

43 Ebola is fragile, but epidemics involving more resilient organisms are possible The medical waste management infrastructure has been impacted by environmental protection requirements The waste disposal issue is also pertinent to emergency radiological waste management

44 Lisa Young Leader, Infection Prevention and Control I BC Emergency Health Services I Provincial Health Services Authority 3300 Douglas Street I Victoria I BC I V8Z 3L1 PO Box 9620 STN PROV GOV I Victoria I BC I V8W 9P1 PHONE: I CELL: I lisa.1.young@bcehs.ca David B. Jansen, P.E., LEED AP Director, Office of Radiation Protection I Division of Environmental Public Health Washington State Department of Health PO Box Israel Rd SE, Tumwater, WA PHONE: I CELL: I david.jansen@doh.wa.gov Web: 44