Appendix 1 - Ebola Virus Disease: Management of Waste and Environmental Cleaning for Prehospital Care and Ground Transport

Foreword

The following guidance provides measures for the safe handling, containment, transport and disposal of waste (including linen and sharps) generated during prehospital care and ground transport from persons under investigation (PUI) and persons confirmed with Ebola virus disease (EVD)^{Footnote a}, along with measures for cleaning the environment contaminated or potentially contaminated with the Ebola virus. Its use is intended for prehospital personnel including, but not limited to, medical first responders, paramedics, emergency ground transport personnel, firefighters, and enforcement officers, along with personnel within prehospital organizations responsible for education and training in occupational health and safety (OHS), IPC and environmental cleaning.

The guidance is based on currently available scientific evidence, standards and regulations, and adopts a precautionary approach where the evidence is lacking or inconclusive. It is subject to review and change as new information becomes available.

The guidance should be read in conjunction with relevant federal, provincial, territorial and local legislation, regulations, and policies, and adapted to local requirements as necessary.

Table of Contents

• Ebola Virus Disease (EVD)
• Recommended Measures for Prehospital Organizations
• Recommended Measures for EVD-associated Waste During Ground Transport
  • Examples of waste
  • Human Waste
  • Linen
  • Other Non-Sharps Waste
  • Sharps Waste
• Recommended Measures for On-site Spills and Environmental Cleaning Related to EVD-associated Blood and Other Body Fluids
• References

Ebola Virus Disease (EVD)

The Ebola virus is categorized as a Risk Group 4 agent, under the Public Health Agency of Canada's Human Pathogens and Toxins Act^{Footnote b}, as it is likely to cause serious disease, and effective treatment is not available. Waste contaminated with the Ebola virus requires special handling and disposal to prevent exposure to the virus^{Footnote 1}.

All EVD-associated waste is considered as regulated biohazardous waste and includes items (including linen) contaminated with human blood and body fluids (i.e., respiratory secretions, saliva, emesis, feces, and urine) that warrants special handling and disposal as it may in certain situations present a risk of disease transmission^{Footnote 2}. EVD-associated waste that has been appropriately incinerated or autoclaved is not infectious and does not pose a health risk^{Footnote 3, Footnote 4}.

The Ebola virus can remain viable on solid surfaces, with concentrations falling slowly over several days^{Footnote 5}. Infectivity has been shown to drop by 90 percent in the first 36 hours^{Footnote 6}, however, given the low infectious dose required for infection and the severity of the disease, the potential for environmental contamination with infected blood and/or body fluids should be considered^{Footnote 5}.

Recommended Measures for Prehospital Organizations

The following measures are recommended for the safe management of EVD-associated waste and environmental cleaning.

• Implement a biohazardous waste management and environmental cleaning program with the development of policies and procedures to include the following:
  • protocols for the management of waste, on-site spills, and environmental cleaning,
  • protocols for adequate supplies of biohazard waste bags and containers/receptacles, cleaning supplies, disinfectants, hand hygiene products and personal protective equipment (PPE),
  • protocols for segregating, packaging, labelling, moving, storing and transporting EVD-associated waste (both on- and off-site),
  • methods for keeping records of the quantities of EVD-associated waste both generated and disposed of,
  • a list of all regulations and legislation concerning EVD-associated waste that are applicable within the organization's/company's jurisdiction,
  • protocols for wearing PPE when handling EVD-associated waste and/or providing cleaning measures that should include:
    • all personnel handling EVD-associated waste and/or providing cleaning services should wear appropriate PPE^{Footnote 7} (i.e., gloves, fluid-resistant or impermeable gown, fluid-resistant mask with eye goggles or fluid-resistant mask with face shield),
    • enhanced PPE^{Footnote 7} (i.e., apron, hazardous material suit, double gloving, head and neck coverings, foot and leg coverings) should be selected and worn based on a risk assessment,
    • regular, ongoing training and education of personnel on proper handling and potential hazards of EVD-associated waste, type and quality of waste containers/receptacles, and PPE selection and use, including how to properly put on and remove PPE^{Footnote 7}. (For information on PPE selection, use, and safely putting on and removing PPE, refer to Infection prevention and control measures for Ebola disease in acute care settings^{Footnote 7}.)
  • provision for regular and ongoing education for Routine Practices^{Footnote 8}, including Hand Hygiene^{Footnote 9} as per PPE protocol, according to organization/company policy, with alcohol-based hand rub (60-90% alcohol) or washing with soap and water, if hands are visibly soiled.
• Assign only personnel trained and educated in occupational health and safety, IPC practices and appropriate selection and use of PPE for the management of EVD-associated waste and environmental cleaning.
• Develop and implement a monitoring system, using a trained observer, for ensuring consistency in safely putting on and removing PPE when handling EVD-associated waste and performing environmental cleaning.
• Develop and implement protocols for the containment and storage of EVD-associated waste as per the organization's/company's biohazardous materials policies, and for off-site transport in accordance with Transport Canada's Transportation of Dangerous Goods Regulations (TDGR)^{Footnote c}, ^{Footnote 10}.
• Determine capability for/availability of transporting EVD-associated waste within their municipality/region and ensure waste is disposed of in accordance with local, municipal or regional requirements and regulations and/or bylaws for regulated infectious waste.
• Provide education to personnel on steps to take when a breach in safe handling and containment occurs resulting in exposure or potential exposure to EVD, during the management of EVD-associated waste.This includes:
  • personnel to immediately stop work, safely remove PPE as per organization/company protocol and leave the area,
  • rinse the affected skin surface with soap and water OR for mucous membrane splashes (e.g., conjunctiva), irrigate with copious amounts of water or eyewash solution, according to the organization's/company's first aid protocol,
  • report immediately according to the organization's/company's exposure/injury protocol, including notification to Public Health authorities, and
  • adhere to follow-up procedures^{Footnote 7, Footnote 11}.

Recommended Measures for EVD-associated Waste During Ground Transport

Examples of waste

1. Human waste - blood and other body fluids (urine, feces, emesis, respiratory secretions and saliva).
2. Linen - bedding, towels, washcloths, gowns.
3. Other non-sharps waste - PPE, disposable bedpans, disposable linen, dressings, sponges, pads, procedure drapes, incontinent products/diapers, cleaning cloths/wipes, mop cloths/wipes, spills, intravenous/gastrointestinal/urine catheters and bags, suctioning equipment/tubing, non-fluid-impermeable pillows or mattresses.
4. Sharps waste - syringes, needles, razors, scalpels.

Human Waste ^{Footnote 5, Footnote 12, Footnote 13, Footnote 14, Footnote 15, Footnote 16, Footnote 17}

• Human waste should only be handled in the care area where it is generated and by personnel wearing appropriate PPE
• Urine, feces and emesis may be disposed of through the normal sanitary sewer system, or in accordance with municipal/regional regulations^{Footnote d}.
  • Where municipal regulatory restrictions exist on disposal through the normal sanitary sewer system, the use of a solidifier for liquid waste (with bedpans - disposable or with liners, and/or disposable emesis basins/receptacle) and disposed of as waste should be considered. (Refer to Other Non-Sharps Waste section)
• In settings where on-site septic sewage disposal systems are used (i.e., septic tanks), no specific measures are required providing the system is operating according to local regulations^{Footnote e}.

Linen ^{Footnote 2, Footnote 5, Footnote 10, Footnote 14, Footnote 16}

• Disposable linen should be used in a prehospital and ground transport setting.
• Handling and containing linen should occur in the care area by trained personnel wearing appropriate PPE.
• Consider all linen in the care area contaminated linen, regardless of whether it was used or not.
• The number of personnel handling linen should be limited.
• Linen should be folded inward and handled with a minimum of agitation and shaking to avoid contamination of air, surfaces and persons.
• For further information on managing and disposing of EVD-associated linen, follow recommended measures under Other Non-Sharps Waste in the next section below.

Other Non-Sharps Waste ^{Footnote 2, Footnote 5, Footnote 10, Footnote 13, Footnote 14, Footnote 15, Footnote 16}

• Handling, containing and removing waste should only occur in the care area by trained personnel wearing appropriate PPE.
• Consider all supplies taken into the care area contaminated, whether used or not.
• The number of personnel handling waste should be limited.
• The following measures are recommended for non-sharps waste:
  • contain waste at point of generation,
  • place waste immediately into a sturdy and leak resistant container lined with a leak and tear resistance plastic biohazard bag,
  • do not manually compact waste in the bags,
  • when the bag is two-thirds full, seal securely preventing tearing/puncturing the bag and ensuring no leaks,
  • remove the bag from the container (Note: this container should stay in the care area until patient discharge to receiving healthcare facility and relined with a new biohazard bag for next fill),
  • decontaminate the entire outside of the bag by wiping using a disinfectant with a broad spectrum virucide claim with a DIN^{Footnote f} and used according to the manufacturer's instructions,
  • place the decontaminated bag into a second biohazard bag and seal securely, preventing tearing/puncturing the second bag and ensuring no leaks,
  • wipe the entire outside of the second bag using a disinfectant with a broad spectrum virucide claim with a DIN used according to the manufacturer's instructions, immediately before removing it from the area.
• To move the double-bagged waste from the care area, (i.e., ground transport vehicle) personnel should place the double bagged waste in a leak-proof/impervious, puncture-resistant plastic or metal single-use container. The waste container should be:
  • located at the periphery/outside of the area for taking off PPE to avoid risk of recontamination of the container during PPE removal,
  • securely sealed, clearly labelled and identified as EVD-associated biohazardous material, by a second person wearing appropriate clean PPE,
  • decontaminated by wiping the entire outside of the container using a disinfectant with a broad spectrum virucide claim with a DIN and used according to the manufacturer's instructions, immediately before removing the container from the area,
  • not be re-opened once sealed.
• For moving large or heavy containers, carts with guard rails or raised edges should be used and loaded in a manner that will prevent items from tipping.
• Carts should be disinfected after each use using a disinfectant with a broad spectrum virucide claim with a DIN and used according to the manufacturer's instructions.
• Containers may be transferred to the receiving hospital if these arrangements have been made in advance OR taken immediately and directly to a designated locked holding area with restricted access and stored as per the organization's/company's biohazardous material policy until ready for transport to disposal site.
• EVD-associated waste storage areas should be clearly marked with a biohazard symbol and kept separate from other storage areas.
• Stored containers of waste should be packaged and transported separately in accordance with Transport Canada's TDGR, and disposed of in accordance with local, municipal or regional requirements and regulations and/or bylaws for regulated biohazardous waste.

Sharps Waste ^{Footnote 14, Footnote 18}

• Sharps should be segregated from other waste and discarded:
  • at point of use,
  • directly into single-use containers, that are leak-proof/impervious, puncture resistant, fitted with securely closed lids and specifically designed for sharps waste.
• Sharps containers should not be filled beyond two-thirds full, to allow for safe closure.
• The following measures for sharps containers are recommended:
  • when the container is two-thirds full, securely close the lid,
  • wipe the outside of the container using a disinfectant with a broad spectrum virucide claim with a DIN and used according to the manufacturer's instructions.
  • place the sharps container into a second leak-proof/impervious, puncture resistant biohazard container,
  • securely seal, clearly label and identify the second container as EVD-biohazardous sharps material,
  • wipe the outside of the second container using a disinfectant with a broad spectrum virucide claim with a DIN and used according to the manufacturer's instructions.
• Containers may be transferred to the receiving hospital if these arrangements have been made in advance OR taken immediately and directly to a designated locked holding area with restricted access and stored as per the organization's/company's biohazardous material policies.
• EVD-associated sharps waste storage areas should be clearly marked with a biohazard symbol and kept separate from other storage areas.
• Stored containers of EVD-associated sharps waste should be packaged and transported separately off-site in accordance with Transport Canada's TDGR, and disposed of in accordance with local, municipal or regional requirements and regulations and/or bylaws for regulated biohazardous waste.

Recommended Measures for on- Site Spills and Environmental Cleaning Related to EVD-associated Blood and Other Body Fluids^{Footnote g, Footnote 5, Footnote 19, Footnote 20}

• All personnel providing cleaning services should be managed by trained personnel wearing appropriate PPE.
• All major spill incidents should be documented, according to organization/company policy for any follow-up required.
• 'Spill kits' should be made available, according to organization/company policy, for use in designated areas.
• The spill area should be isolated from access to other individuals until cleaning and disinfection is completed.
• Special cleaning of upholstery and carpets is not indicated unless they are visibly soiled with blood or other body fluids.
  • items visibly soiled (e.g., upholstery, cloth chairs, cloth seats, seat covers or carpets covered in blood or other body fluids) that are difficult to clean should be removed and treated as waste.
• All surfaces, areas, items and objects visibly contaminated or potentially contaminated with blood or other body fluids should be cleaned and disinfected (e.g., walls, floors, locks, counters, door knobs, light switches, tables/work surfaces, other high contact surfaces and items/objects).
• Visible blood and other body fluids should be removed first with disposable damp cleaning cloths or wipes and regular detergent.
• The following cleaning and disinfection measures are recommended:
  • allow fluid and droplets to settle, fluids should not be permitted to fully dry,
  • gently cover a spill with disposable absorbent paper towels, wipes or pads (a solidifier agent may be used); remove organic/bulk material, and place waste immediately into sturdy, leak and tear resistant biohazard plastic bag and securely seal (Refer to Other Non-Sharps Waste section for further details),
  • with disposable cleaning cloths or wipes, apply a disinfectant with a broad spectrum virucide claim with a DIN to the surface and allow sufficient contact time according to manufacturer's instructions,
  • spraying disinfectant or using wet vacuum should not be done in order to avoid any splashes and splatter; compressed air, pressurized water or similar procedures which might create droplets, should not be used; dry sweeping and dusting with a broom or cloth should not be done,
  • start at one end of the affected area and move in one direction until all surfaces have been disinfected; do not use a circular motion^{Footnote 19},
  • use cleaning cloths, wipes, etc., only once and after use, discard all cleaning items immediately into a biohazard bag located within reach (Refer to Other Non-Sharps Waste section).
• Patient's personal items visibly soiled with blood or other body fluids should be cleaned and disinfected as per above. If items cannot be properly clean and disinfected, they should be treated as waste.