Management of Ebola waste in a clinical setting Multilateral - - PowerPoint PPT Presentation

Multilateral agreement M281

Management of Ebola waste in a clinical setting

Gijsbert van Willigen Health, Safety & the Environment

LEIDEN UNIVERSITY MEDICAL CENTER

Marburg patient LUMC 2008

• Woman of 41 years old
• Round trip through Uganda:
• Visited:
• Bat caves
• Gorillas
• Pygmies
• Swimming in fresh water
• Several insect bytes
• Hospitalization on July 5th.
• Reason for hospitalization: fever
• Lab-tests: malaria, typhoid fever and other tropical diseases. All results were

negative

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Marburg patient LUMC 2008

• July 7th: Transfer of the patient to the LUMC for liver transplant
• Low suspicion for a viral hemorrhagic fever
• Patient was isolated and nursed according to the protocol of very contagious

disease

• July 9th:
• Suspicion became high for Ebola or Marburg
• Testing for Ebola and Marburg is send in to Rotterdam (ErasmusMC, the

Netherlands) and Hamburg (Bernhard Nocht Institute, Germany)

• July 10th:
• Patient died early in the morning
• Positive diagnoses for Marburg late in the morning

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Protocol for very contagious diseases

• Hospital staff nursing and treating the patient had to wear PPE’s:
• Coverall, respiratory protection, goggles, double gloves, apron etc.
• All waste was collected in autoclavable medical waste containers:
• Used PPE’s
• Bed linen
• Secreta and excreta of the patient
• Everything that entered the isolation room was discarded as waste
• After the patient died the room prepped for VHP-decontamination:
• Only equipment and the bed stayed in the room
• Everything else was discarded as waste, incl.:
• matrass, curtains
• unused disposables etc. etc.

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An “empty” room

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Waste management

• Waste was collected in medical waste bins UN3291 with sterilid:
• Laboratory waste
• Waste from the isolation room
• Collected waste was stored in a secured location pending for further

processing

• No waste bins for collection of UN2814 waste available

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Waste management

• Amounts of collected waste:
• Laboratories:
• 12 containers (6 of 30 liter and 6 of 50 liter)
• Isolation room:
• 72 containers of 50 liter
• Total amount of waste collected in 72 hours:
• 3500 liter or 1000 kg
• Normally 450 medical waste containers of 50 liters in 72 hours for the entire

Leiden University Medical Center (~450 patients)

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Waste management

• Medical waste bins comply to P621 and not to P620:
• No transport of the waste allowed to the incinerator
• Inactivation should take place within the medical center
• Inactivation of the waste:
• 4 destruction autoclaves
• 2 bins per autoclave run
• 2 operators
• 4 days
• 10 hours a day

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Waste management

Available autoclave capacity in the Netherlands:

• Leiden University Medical Center
• Amsterdam Medical Center
• Erasmus Medical Center
• Other medical centers no or insufficient capacity
• In Belgium no capacity available

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Waste containers for UN2814/P620

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Mauser Alex Breuer (DE) Carepack (NL) VE Systems

Waste containers for UN2814/P620

Advantage:

• Transport of non treated UN2814 waste is possible
• No in-house destruction needed

Disadvantages:

• Bins are not a daily routine for the nursing staff
• Increased risk:
• Small filler neck of the bins
• Small volume and allowed weight (around 7 kilo’s)
• Sharp edges
• Not easily purchased, small stock at supplier
• Expensive

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Multilateral agreement M281

• Meeting from delegations from Belgium and the Netherlands:
• Biosafety experts
• Experts infection prevention
• Competent authorities (Transport, Public Health)
• Waste transporters
• Incineration plant (Zavin, NL; Indaver, BE)
• Goal: find an alternative method for Ebola waste management
• Alternative should be safe (collection, transport and incineration)
• Approval from all parties
• Initiate the process for a multi-lateral agreement at UNECE (UN Economic

Commission Europe ; ADR)

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Multilateral agreement M281

Prerequisite: method should be safe

• Collection:
• Preferably the UN3291 should be used
• Transport:
• Packaging for transport to the incinerator should offer similar safety as existing

UN2814 / P620 packaging

• Incineration plant:
• The waste must be processed in the normal operation of the incinerator

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Multilateral agreement M281

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Multilateral agreement M281

The solution, a combination packaging consisting of:

• Primary packaging: P621 waste container or 1H2 barrel
• Closed and leak proof
• Secondary packaging: plastic bag minimal 75um
• Closed and leak proof
• Contains absorption material
• Tertiary packaging: 1H2 barrel or 4H2 box
• Closed and leak proof
• Should fit the feeding opening of the incinerator

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Multilateral agreement M281

5-Nov-15 Management of Ebola waste 16 Sluit het 120 L vat * met het bijhorende deksel. Zet het deksel vast met de ringsluiting.

Primary packaging Secondary & tertiary packaging

1H2 barrel P621/UN3291

Multilateral agreement M281

COUNTRY SIGNED REVOKED Belgium 14/11/2014 Germany 27/11/2014 Netherlands 4/12/2014 Switzerland 8/12/2014 Luxembourg 12/12/2014 Austria 3/08/2015

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Multilateral agreement M281

Experience in the Netherlands:

• 1 positive Ebola patient
• All parties involved were positive on the procedure described in M281

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Multilateral agreement M281

Unfortunately M281 expires January 1, 2017 Should we:

• Prolong M281 after January 1, 2017, if possible
• Embed the procedure in ADR

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