Handling VHF-Associated Waste

• The handling, transport, treatment, and disposal of waste generated during the care of patients under evaluation or with confirmed VHF is subject to procedures set forth by local, state, and federal regulations.
• Except for Chapare virus*, these selected hemorrhagic fever viruses are Category A infectious substances. A Category A infectious substance is regulated as a hazardous material under the U.S. Department of Transportation (DOT) Hazardous Materials Regulations (HMR; 49 CFR, Parts 171-180). Requirements in the HMR apply to any material DOT determines is capable of posing an unreasonable risk to health, safety, and property when transported in commerce1. For off-site commercial transport of VHF-associated waste, strict compliance with the HMR is required.
  • If a person requires a variance to the HMR, that person must apply for a Special Permit under 49 CFR § 107.105.
  • See U.S. Interagency Planning Guidance for Handling Category A Solid Waste for more details.

• Primary healthcare providers (e.g., physicians and nurses) wearing PPE should conduct handling and primary packaging of waste in the patient room.
• Inactivation or incineration of VHF-associated waste within a hospital system may be subject to state, local, and OSHA regulations. Category A viral hemorrhagic fever-associated waste that has been appropriately incinerated, autoclaved, or otherwise inactivated is not infectious, does not pose a health risk, and is not considered to be regulated medical waste or a hazardous material under federal law. Therefore, such waste no longer is considered a Category A infectious substance and is not subject to the requirements of the HMR.

1. Safe containment and packaging of waste should be performed as close as possible to the point of generation. Staff should avoid opening containers to manipulate the waste after primary containment.
2. Limit the number of personnel entering the VHF patient care area and those handling generated waste before and after primary containment.
3. Always use appropriate personal protective equipment (PPE) and procedures for handling waste until onsite inactivation or transport away from the hospital for offsite inactivation.

1. Comply with federal, state and local regulations for handling, storage, treatment, and disposal of VHF-associated waste.
2. Ensure effective communication between healthcare facilities, waste management vendor, and state, local, and federal regulators.
3. Determine whether VHF-associated waste will be inactivated onsite at the hospital or transported offsite for inactivation.
   1. Onsite inactivation: VHF-associated waste may be inactivated with appropriate autoclaves. Waste should be packaged and autoclaved according to manufacturer’s instructions. Other methods of inactivation (e.g., chemical inactivation) have not been standardized and would need to consider worker safety issues, as well as the potential for triggering other federal safety regulations.
   2. On-site incineration: VHF-associated waste may be incinerated. The products of incineration (i.e., the ash) can be transported and disposed of in accordance with state and local regulations and standard protocols for hospital waste disposal.
   3. Offsite inactivation: Comply with federal, state, and local regulations for packaging, transport and disposal of VHF-associated waste.
4. Identify a dedicated waste management team with specific training on standardized procedures for waste handling, including wearing appropriate PPE, and protocols for safely bagging and packaging waste, storing waste, and transporting packaged waste.
5. When selecting emergency department triage areas for the evaluation of patients with possible VHF, a designated area should be identified for waste storage pending a determination of whether the patient has VHF or not. The storage space should meet all applicable fire codes and principles of maintaining a clutter-free, safe environment.
6. Be sure healthcare personnel and environmental services staff handling waste are trained to wear recommended PPE and follow appropriate putting on and taking off procedures. Use the appropriate PPE [PDF – 3 Pages] for environmental services and waste collection workers handling, transporting, and disposing of waste.

Solid waste generated during VHF (except Chapare) patient care is classified as Category A waste and may include medical equipment, sharps, linens, used healthcare products such as soiled absorbent pads or dressings, kidney-shaped emesis pans, portable toilets, used PPE (gowns, masks, gloves, goggles, face shields, respirators, booties, etc.), or byproducts of cleaning. Any contaminated or potentially contaminated item that (1) cannot be inactivated on-site and (2) needs to be transported offsite for treatment and disposal must be packaged and transported in accordance with the U.S. Department of Transportation's (DOT) Hazardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180) or under the terms of a DOT special permit*, local and state regulations, and waste management vendors' specifications. Hospitals should work with their waste transporters (i.e., waste haulers or carriers) on the specific packaging steps and requirements for VHF-associated waste. Additional guidance can be found on the U.S. Interagency Planning Guidance for Handling Category A Solid Waste.

In general, there are two steps to packaging VHF-associated medical waste: primary packaging and secondary packaging (see DOT-Special Permit 16279 for additional details). Healthcare personnel should understand packaging requirements and steps prior to handling VHF-associated medical waste to reduce the risk of opening or rehandling waste. In addition, healthcare personnel should consider the following:

• All placement of receptacles (including sharps containers) and primary packaging by double-bagging of waste should occur in the patient's room and be performed by the primary healthcare workers (i.e., physicians and nurses) wearing PPE.
• In the doffing area, the designated waste container should be located at the periphery of the area so that removal is efficient and does not create a risk of recontamination of the outer container.
• Healthcare personnel, including environmental services personnel, with appropriate PPE should use a designated transport cart when transporting double-bagged waste to dedicated waste autoclave room for onside inactivation or to the rigid outer receptacle for offsite inactivation. They should only handle the transport cart or outer receptacle.
• Packaged VHF-associated waste for offsite inactivation and disposal should be stored in a designated and secure storage area for waste hauler pickup. It is recommended that the area be isolated with limited personnel access.

Consult with state or local regulations regarding pretreatment of VHF-associated waste. Sanitary sewers may be used for the safe disposal of patient waste. Reference WHO Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola, 2014 [PDF – 24 pages].

1. Primary handling of liquid waste should occur in the patient's room and be performed by the primary healthcare workers (i.e., physicians and nurses) wearing recommended PPE.
2. Pour waste, avoiding splashing by pouring from a low level, into the toilet.
3. Close the lid first, and then flush toilet.
4. Clean and disinfect flush handles, toilet seat, and lid surfaces with an EPA-registered hospital disinfectant/cleaner from List Q; for Ebola, products from List L can also be used.
5. Discard cleaning cloths in biohazard bags.
6. Discard emesis and portable toileting containers as solid waste.
7. Follow recommended procedures for removal of PPE.

Basic principles for spills of blood and other potentially infectious materials are outlined in the U.S. Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard, 29 CFR 1910.1030 and guidance for Bloodborne Pathogens and Needlestick Prevention.

1. Spills should be managed by the physicians and nurses caring for the patient and by wearing recommended PPE.
2. Isolate the area of the spill; do not let other individuals access the area until disinfection is completed.
3. Place absorbent material on the spill (a solidifier agent can be used). Pour the EPA-registered hospital disinfectant from List Q (for Ebola, products from List L can also be used) over the spill and allow sufficient contact time according to label's instructions for treating spills.
4. Use disposable absorbent towels to remove bulk spill material. Dispose of the towels in a biohazard bag as specified above.
5. Apply the EPA-registered hospital disinfectant from List Q (for Ebola, products from List L can also be used) with disposable cloths to the cleaned surface and disinfect according to the label's instructions for use and the specified contact time.
6. Follow handling of solid waste protocol as described above to discard materials used for containing the spill and for cleaning and disinfection.
7. Follow recommended procedures for doffing PPE.