We are sometimes asked if we have written procedures or protocols regarding packaging, labeling, transporting and disposing of various “hazardous materials/infectious agents”. Management of Ebola outbreak situations is the catalyst for the most recent wave of inquiry so we’re offering information and resources that will help to educate you and your staff.
Management of those who treat infected or potentially infected patient populations are regulated by recommendations of the Centers for Disease Control (CDC), the World Health Organization (WHO) and enforcement by United States Occupational Safety and Health Administration (OSHA). Most frequently cited are Bloodborne Pathogen Standards (29 CFR 1910.1030) but other OSHA regulations do apply.
Handling, labeling and storage of contaminated waste, while at the treatment facility are also covered by Bloodborne Pathogen Standards, but must be packaged and transported in accordance U.S. DOT Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180) when taken off site for destruction.
As part of any situation where care of patients who are persons under investigation, or with probable or confirmed Ebola virus infections, we recommend adhering to the CDC recommendations as follows:
- Be sure environmental services staff wear recommended personal protective equipment (PPE)to protect against direct skin and mucous membrane exposure of cleaning chemicals, contamination, and splashes or spatters during environmental cleaning and disinfection activities. If reusable heavy-duty gloves are used for cleaning and disinfecting, they should be disinfected and kept in the room or anteroom. Be sure staff are instructed in the proper use of personal protective equipment including safe removal to prevent contaminating themselves or others in the process, and that contaminated equipment is disposed of appropriately.
- Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection. Although there are no products with specific label claims against the Ebola virus, enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces. In contrast, non-enveloped viruses are more resistant to disinfectants. As a precaution, selection of a disinfectant product with a higher potency than what is normally required for an enveloped virus is being recommended at this time. EPA-registered hospital disinfectants with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) are broadly antiviral and capable of inactivating both enveloped and non-enveloped viruses.
- Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic or other covering that fluids cannot get through. Do not place patients with suspected or confirmed Ebola virus infection in carpeted rooms and remove all upholstered furniture and decorative curtains from patient rooms before use.
- Routine cleaning and disinfection of the PPE doffing area. Routine cleaning of the PPE doffing area should be performed at least once per day and after the doffing of grossly contaminated PPE. Cleaning should be performed by a HCW wearing clean PPE. An EPA-registered hospital disinfectant with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) should be used for disinfection. When cleaning and disinfection are complete, the HCW should carefully doff PPE and perform hand hygiene.
- To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains into the waste stream and disposed of appropriately.
Cleaning and Decontamination Protocols
OSHA has set minimal requirements for cleaning and decontamination of equipment and work surfaces that come into contact with blood and/ or OPIM.
Contaminated equipment and work surfaces in each treatment area will be cleaned and disinfected after each patient if it is determined that contamination has occurred.
- Decontamination will be performed using accepted, appropriate disinfectants.
- Contaminated instruments and reusable sharps will be cleaned, sterilized, and/ or discarded after each patient.
- Reusable sharps that are contaminated with blood or OPIM will not be stored or processed in a manner that requires reaching by hand into containers where these sharps have been placed.
- Contaminated disposable sharps will be discarded in sharp containers immediately or as soon as possible.
- Bins, pails, cans, and similar receptacles will be inspected daily and cleaned immediately or as soon as feasible upon visible contamination.
- Broken glass which may be contaminated will not be picked up directly with hands. Utility gloves, a brush and dustpan, tongs or forceps, and a disposable towel or sponge should be used and the broken glass placed in a sharps container.
- Detailed methods for cleaning various and specific areas at your facility should be defined by Infection Control Officer for you operations.
Basic principles for blood or body substance spill management are outlined in the Bloodborne Pathogen Standards (29 CFR 1910.1030).
Blood Spill Protocols
All spills of blood and blood-contaminated fluids should be promptly cleaned up using a hospital grade disinfectant in the following manner:
- Put on utility gloves before beginning the clean-up procedure. Wearprotective eyewear and/ or shield with mask, and an impervious gown or apron which will serve as an effective barrier if necessary.
- Remove visible material with absorbent towels or other appropriate meansthat will ensure that there is no direct contact with blood.
- Wash surface with soap and water or a germicide and apply a disinfectantand allow the surface to air dry.
- Clean and disinfect soiled cleaning equipment or place in an appropriatecontainer for disposal.
- Wash hands following removal of gloves.
Note: Shoes and footwear can become contaminated with blood in certain circumstances. Where there is massive blood contamination on floors, the use of disposable impervious shoe coverings should be considered. Gloves must be worn when removing shoe coverings. The coverings and gloves should be disposed of in plastic bags.
Before cleaning up any spills of blood or OPIM, report any cut, scrape, wound, chapped skin, skin rash, dermatitis, etc., that you may have to your employer or Infection Control Officer.
If you should splash blood or OPIM into your eyes, nose, or mouth, or if you spill any blood or OPIM on your skin where there is a cut, wound, chapped skin, skin rash, or dermatitis, immediately wash the skin area thoroughly and report the incident to your employer or Infection Control Officer as soon as possible.
Use a chemical disinfectant with sufficient potency is needed to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant’s active ingredient. An EPA-registered hospital disinfectant with label claims for non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) and instructions for cleaning and decontaminating surfaces or objects soiled with blood or body fluids should be used according to those instructions.
These materials should be placed in leak-proof containment and discarded appropriately. To minimize contamination of the exterior of the waste bag, place this bag in a rigid waste receptacle designed for this use. Incineration or autoclaving as a waste treatment process is effective in eliminating viral infectivity and provides waste minimization. If disposal requires transport offsite then this should be done in accordance with the U.S. Department of Transportation’s (DOT) Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180). Guidance from DOT has been released for Ebola.
When transported for destruction, Ebola contaminated waste is considered to be an infectious substance and regulated by the U.S. Department of Transportation’s (DOT) Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180). The Ebola virus is a classified as a Category A, infectious substance. It is considered to be a material known or reasonably expected to contain a pathogen 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.
Any item transported offsite for disposal that is contaminated or suspected of being contaminated with a Category A infectious substance must be packaged and transported in accordance with the HMR. This includes 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 with a Category A infectious substance.
Packaging Preparation: Bag the waste in plastic film bags and place in a rigid outer packaging. Note: Individual plastic film bags may weigh no more than 10 kg (22 lbs.) when filled. An outer packaging may contain more than one set of triple bagged waste.
Follow all appropriate occupational safety and health requirements in place by regulating agencies and your facility:
- Place the potentially contaminated waste into the first plastic bag;
- Prior to closure, treat potentially contaminated waste with an U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) that is recommended by the CDC for use as a disinfectant for the Ebola virus. Please review product label to ensure it meets these requirements;
- Place sharps waste in an authorized sharps container, and close and seal it in accordance with the packaging instructions for that container;
- Wrap objects with sharp edges to prevent the tearing or puncture of the plastic bag;
- Close the plastic film bag by tying the bag with a knot or other equally effective positive means of closure that will not tear or puncture the outer bag or liner such as heat sealing, tape, or adhesive, and will ensure any liquid contents will not leak from the packaging; and,
- Disinfect the exterior surface of the plastic bag with an EPA-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) that is recommended by the CDC for use as a disinfectant for the Ebola virus.
- Place the first plastic film bag, with the knot facing upward, into a second plastic film bag;
- Close the second plastic film bag by tying the bag with a knot or other equally effective positive means of closure that will not tear or puncture the outer bag or liner such as heat sealing, tape, or adhesive, and will ensure any liquid contents will not leak from the packaging. Make sure the primary bag does not interfere with closing the second bag;
- Disinfect the exterior surface of the second bag with an EPA-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus that is recommended by the CDC for use as a disinfectant for the Ebola virus.
Step 3 – Preparation of outer packaging
- The outer package must be either a rigid UN Standard or DOT Approved non-bulk packaging. If the outer packaging is fabricated from fiberboard, it must be a minimum of triple wall and contain a 6 mil polyethylene plastic liner.
- Place absorbent material sufficient to absorb all free liquid (if any) in the bottom of the rigid outer packaging or the liner of the fiberboard outer packaging;
- Place the double bagged waste into the rigid outer packaging or into the outer fiberboard packaging with an installed liner;
- Close the liner (if used) either by zip tie or other equally effective means of closure or as specified by the manufacturer of the packaging;
- Securely close the outer packaging as specified by the manufacturer of the packaging;
- Disinfect the exterior surface of the package with an EPA-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus that is recommended by the CDC for use as a disinfectant for the Ebola virus.
Most Important …. Education, Training and Preparation.
Refresher and up-dated education to workers regarding this evolving epidemic, training to include the general controls recommended (above) by the CDC and preparation will go far to ensure the safety of staff, patients and the general public.
Additional information can be found at:
This information has been influenced by CDC Guidelines
(Article by Marc Selman)