Re: Ebola Waste

[Terry Grimmond]

Hi Verily,

Thank you for comment. May I update you and members on events in last 48
hrs.

The issue is not *destruction* of Ebola waste. As you say, all approved
mechanisms for Clinical Waste (CW) destruction are effective. Ive no
concerns here, and neither does Australian Communicable Disease Network
Authority (CDNA).

The contentious issue is *transport* of Ebola waste. CDNA issued sound
advice to double-bag Ebola waste in leakproof bags. But this is over-ridden
by Australian Dangerous Goods (ADG) regulations which currently require
Ebola substances *in any form* to be UN2814 triple-packaged under the
strict ADG P620 regime. But there are no P620 packaging systems large
enough to take Ebola waste, and to transport Ebola waste in anything else
requires approval from your state competent authority.

*However *On Friday Oct 31st, SteriHealth was granted Australias first
Ebola alternative packaging approval by Worksafe NSW. But it is only
applicable in NSW. The Ebola Task Force is on top of the issue and its
Head, Prof Lyn Gilbert said on Thursday, *..the committee’s first task
would be gaining consensus between the states and territories on the best
protocols for activities such as transporting specimens and clinical
waste.*

The ADG lists 61 Category A pathogens requiring UN2814 packaging however
I cannot recall in my career any waste from these patients being
transported as UN2814. I believe the ADG, and the UNTDG on which the ADG is
modeled, need a safe, practical means of transporting these wastes.

Kind regards, Terry

Terry Grimmond FASM, BAgrSc, GrDpAdEd

Consultant Microbiologist

Grimmond and Associates

Ph (NZ): +64 7 855 3212

Mob (NZ): +64 274 365 140

E: terry@terrygrimmond.com

[image: Twitter_logo_blue]: @terrygrimmond

W: http://terrygrimmond.com

“This email (including any attachments) is intended only for the use of the
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confidential and privileged. If you are not the intended recipient, you are
reminded that any dissemination, distribution or copying of this email or
attachments is prohibited. If you have received this email in error, please
notify me immediately by return email or telephone and destroy the original
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*From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
Behalf Of *Verily Thomas
*Sent:* Friday, October 31, 2014 5:22 PM
*To:* AICALIST@AICALIST.ORG.AU
*Subject:* Re: Ebloa Waste

Hi All

This has been a very worrying issue especially considering that what we are
most concerned about is blood and body fluids with EBV.We have taken care
of the entry side of it but the waste management bit I am not so sure may
be wrong.

Is the waste not hazardous if it is not properly treated as in autoclaved,
incinerated or treated in any other way to render it nonhazardous? Does our
clinical waste guidelines cover this as it would be concerning if this
waste is not properly disposed of and ends up being a problem with
community spread, just saying. Still trying to figure out which waste it
fits under really particularly where the quality of some of the clinical
waste bags is not very ideal, as in paper thin, with incidents of body
fluid exposure due to tears especially when the bags are very heavy.

Just a thought I have tried to look under the EPA guidelines nothing much
coming up on infectious waste would be good to know what the majority are
doing.- http://www.cdc.gov/vhf/ebola/hcp/medical-waste-management.html

Kind Regards

*Verily Thomas*
Clinical Nurse Consultant | *Infection Prevention and Control*
SWSLHD-Bankstown/Lidcombe Hospital

Eldridge Road, Bansktown.NSW 2200
Tel 02 97228000 pager 28230

Tel 02 9722 8633 | Fax 02 9722 7822 | verily.thomas@sswahs.nsw.gov.au
http://www.health.nsw.gov.au

[image: Description: cid:image002.jpg@01CE8EA5.483A6E60]

*LET’S KEEP OUR HOSPITAL ENVIRONMENT CLEAN*

*HAND HYGIENE SAVES LIVES*

*From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU
] *On Behalf Of *Terry Grimmond
*Sent:* Friday, 31 October 2014 11:51 AM
*To:* AICALIST@AICALIST.ORG.AU
*Subject:* Re: Ebloa Waste

Hi Sony,

I agree with you. But for countries who have harmonized with UNTDG Model
Recommendations, Ebola is Category A UN2814. It is not Clinical Waste
UN3291. The national law steps in and CDC and DoH recommendations are
over-ruled. As happened in USA last month where DOT over-ruled CDC on this
issue.

Best regards, Terry

Terry Grimmond FASM, BAgrSc, GrDpAdEd

Consultant Microbiologist

Grimmond and Associates

Ph (NZ): +64 7 855 3212

Mob (NZ): +64 274 365 140

E: terry@terrygrimmond.com

[image: Twitter_logo_blue]: @terrygrimmond

W: http://terrygrimmond.com

“This email (including any attachments) is intended only for the use of the
individual or entity named above and may contain information that is
confidential and privileged. If you are not the intended recipient, you are
reminded that any dissemination, distribution or copying of this email or
attachments is prohibited. If you have received this email in error, please
notify me immediately by return email or telephone and destroy the original
message. Thank you.”

*From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
Behalf Of *Sony SO
*Sent:* Friday, October 31, 2014 12:58 PM
*To:* AICALIST@AICALIST.ORG.AU
*Subject:* Re: Ebloa Waste

Dear All,

The issue of using single clinical bag for handling infectious materials
i.e. clinical waste is addressed in the CDC guidelines-*Guidelines for
Environmental Infection Control in Health-Care Facilities *
http://www.cdc.gov/~HCF_03.pdf
, details are
as follows:

point I, (3), page 119, which states: A single, leak-resistant
biohazard bag is usually adequate for containment of regulated medical
wastes, provided the bag is sturdy and the waste can be discarded without
contaminating the bags exterior.

Point G, (3), page 100, which states: Single bags of sufficient
tensile strength are adequate for containing laundry, but leak-resistant
containment is needed if the laundry is wet and capable of soaking through
a cloth bag.1264

Furthermore, with reference to international guidelines related to
clinical waste management(Table 1), practices of double bagging of waste is
not recommended.

Lastly, practices of double-bagging of items from isolation rooms is not
considered as an infection control measure, for details, please refer to:

Maki DG, Alvarado C, Hassemer C. Double-Bagging of Items from Isolation
Rooms Is Unnecessary as an Infection Control Measure: A Comparative Study
of Surface Contamination with Single-and Double-Bagging. Infection Control.
1986; 7(11): 535-7. Available from: http://www.jstor.org/stable/30146425

Regards,

Sony SO

Nursing Officer, Infection Control Branch (Team 2)

Centre for Health Protection

office phone: +852 2125-2922; fax: +852 3523-0752

HA email sony@ha.org.hk; DH email no_icb4@dh.gov.hk

Please consider the environment before printing this e-mail

Table 1: international guidelines for handling clinical waste

1. Biohazard Waste Industry Australia and New Zealand
(BWI) (formerly ANZCWMIG). (2007). Industry Code of Practice for the
Management of Clinical and Related Wastes. Retrieved 11 August 2010 from
http://www.epa.sa.gov.au/xstd_files/Waste/Code%20of%20practice/Code%20of%20Practice%206th%20Edition.pdf

2. UK Department of Health. Environment and sustainability Health
Technical Memorandum 07-01: Safe management of healthcare waste Retrieved
August 2014 from
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167976/HTM_07-01_Final.pdf

3. Uk Health & Safety Executive. (2009). Carriage of Dangerous
Goods Manual-Carriage of clinical waste Retrieved 11 August 2010 from
http://www.hse.gov.uk/cdg/manual/clinical/index.htm

4. World Health Organization WHO. (2008). Safe Management of
Wastes from Health-Care Activities. Retrieved August 2014 from
http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf

5. (2003)201410
http://www.moh.gov.cn/mohyzs/s3576/200804/18353.shtml

6. (1997)(97) 201410
http://wm.epa.gov.tw/medicalwaste/Documents/HandBook39all3.pdf

*From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU
] *On Behalf Of *Michael Wishart
*Sent:* Friday, October 31, 2014 5:20 AM
*To:* AICALIST@AICALIST.ORG.AU
*Subject:* Ebloa Waste

[This message is posted on behjalf of Belinda Henderson, ACIPC President.
Note that this issue has been discussed through the ACIPC Executive Council
at National and State/juristictional level. ICPs are urged to check with
their state/juristiction authorities and local waste contractors regarding
any local impact of this issue Moderator]

We want to update our members on the issue of Ebola Waste transport in
Australia. One of our members, Terry Grimmond, has been working with
authorities to develop a practical, safe and legal packaging solution so we
asked him to summarise where Australia is at.

Thank you Belinda,

Many ACIPC members will have seen the Oct 3 CDNA/AHPPC recommendations for
double-bagging Ebola waste and transporting it as clinical waste1 (i.e.
shipping as UN 3291). These recommendations are sound and evidence-based.

However, what many may not know is that the Australian Dangerous Good Code
(ADG)2 requires substances *known or reasonably expected to contain a
Category A Infectious Substancein any form* (e.g. Ebola waste) to be
packaged according to ADG P620 requirements, which require:

a 95k Pa pressure-tested, leakproof primary receptacle that is
sealed and placed inside a:

leakproof secondary receptacle containing absorbent material,
sealed and placed inside:

a rigid outer container certified to ADG 9m drop, Rod Impact, and
Water-spray tests.

The issue is, P620 packaging is designed for specimens, cultures, etc and
no P620 packaging exists for large Category A items such as waste bags,
mattresses, etc.

If waste companies pick up Ebola waste in anything other than P620
packaging, they would be breaking the law. Alternative packaging systems
must be approved as *safe as ADG P620*.

Submissions need be made to the competent authority (CA) in each state
(no Federal CA) and an approval in one state is not applicable in another,
so multiple submissions need be made.

With the CDNA recommendation (*double-bag and handle as clinical waste*
(CW), the medical waste firm SteriHealth saw the compliancy issue early
(same occurred in USA with CDC and DOT) and retained me to work with CA to
develop a triple-packaging system of equivalent safety to ADG. The
Biohazard Waste Industry is also working with CA to obtain packaging
approvals.

I worked with WorkCover NSW for several weeks and, after developing a
leakproof sealing system for CW bags, and consultation with Westmead
Hospitals IPs (Kath Dempsey, Jo Tallon), we have developed a
triple-packaging system we believe is of equal safety to ADG P620.
Multi-sized systems will need be approved but in this instance I submitted
a system with a high chance of approval so that at least one system was
available.

WorkCover NSW hope to release their decision tomorrow [31 October
Moderator]. Hopefully an approval in NSW will make submissions easier and
faster in other states.

Yesterday [29 October Moderator] I spoke with Prof Lyn Gilbert, Head of
Ebola Task Force and Prof Chris Baggoley, Chief Medical Officer, Australian
Dept of Health and they have scheduled the item for discussion this week to
examine means of expediting the submission process Australia-wide.

Terry Grimmond FASM, BAgrSc,
GrDpAdEd

Consultant Microbiologist, Grimmond and Associates

terry@terrygrimmond.com

1. Ebola Virus Disease (EVD). CDNA NATIONAL GUIDELINES FOR PUBLIC
HEALTH UNITS 3 Oct 2014. Communicable Disease Network Authority, Australian
Department of health.
http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-ebola.htm/$File/EVD-SoNG.pdf.

2. The Australian Dangerous goods Code Ed 7.3(2014).
http://www.ntc.gov.au/heavy-vehicles/safety/australian-dangerous-goods-code/.

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[Sony SO]

Dear All,

The issue of using appropriate waste bags is addressed in the Ebola Virus Disease (EVD) CDNA NATIONAL GUIDELINES FOR PUBLIC HEALTH UNITS, page 54, Appendix 13 Waste treatment and disposal Waste
http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-ebola.htm/$File/EVD-SoNG.pdf, which states: Items stained or containing body fluids are treated as clinical waste. Clinical waste bags must adhere to Australian Standards and be leak proof. Facilities should have a system of double bagging the clinical waste. This should involve keeping the first clinical waste bags inside the patient room and then placing these bags inside a second clinical waste bag kept outside the patient room

For now, in HK, we do not have standard/specification regarding waste bags leak proof or resistance properties. Hence, would you please provide information in this regard to us for reference.

Regards,

Sony SO

Nursing Officer, Infection Control Branch (Team 2)

Centre for Health Protection

office phone: +852 2125-2922; fax: +852 3523-0752

HA email sony@ha.org.hk; DH email no_icb4@dh.gov.hk
Please consider the environment before printing this e-mail

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Terry Grimmond
Sent: Saturday, November 01, 2014 1:03 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Ebola Waste

Hi Verily,
Thank you for comment. May I update you and members on events in last 48 hrs.
The issue is not destruction of Ebola waste. As you say, all approved mechanisms for Clinical Waste (CW) destruction are effective. Ive no concerns here, and neither does Australian Communicable Disease Network Authority (CDNA).
The contentious issue is transport of Ebola waste. CDNA issued sound advice to double-bag Ebola waste in leakproof bags. But this is over-ridden by Australian Dangerous Goods (ADG) regulations which currently require Ebola substances in any form to be UN2814 triple-packaged under the strict ADG P620 regime. But there are no P620 packaging systems large enough to take Ebola waste, and to transport Ebola waste in anything else requires approval from your state competent authority.
However On Friday Oct 31st, SteriHealth was granted Australias first Ebola alternative packaging approval by Worksafe NSW. But it is only applicable in NSW. The Ebola Task Force is on top of the issue and its Head, Prof Lyn Gilbert said on Thursday, ..the committee’s first task would be gaining consensus between the states and territories on the best protocols for activities such as transporting specimens and clinical waste.

The ADG lists 61 Category A pathogens requiring UN2814 packaging however I cannot recall in my career any waste from these patients being transported as UN2814. I believe the ADG, and the UNTDG on which the ADG is modeled, need a safe, practical means of transporting these wastes.

Kind regards, Terry

Terry Grimmond FASM, BAgrSc, GrDpAdEd
Consultant Microbiologist
Grimmond and Associates
Ph (NZ): +64 7 855 3212
Mob (NZ): +64 274 365 140
E: terry@terrygrimmond.com
[cid:image002.png@01CFF599.7553EEB0]: @terrygrimmond
W: http://terrygrimmond.com
[cid:image003.gif@01CFF594.836716D0]
“This email (including any attachments) is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are reminded that any dissemination, distribution or copying of this email or attachments is prohibited. If you have received this email in error, please notify me immediately by return email or telephone and destroy the original message. Thank you.”

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Verily Thomas
Sent: Friday, October 31, 2014 5:22 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Ebloa Waste

Hi All
This has been a very worrying issue especially considering that what we are most concerned about is blood and body fluids with EBV.We have taken care of the entry side of it but the waste management bit I am not so sure may be wrong.
Is the waste not hazardous if it is not properly treated as in autoclaved, incinerated or treated in any other way to render it nonhazardous? Does our clinical waste guidelines cover this as it would be concerning if this waste is not properly disposed of and ends up being a problem with community spread, just saying. Still trying to figure out which waste it fits under really particularly where the quality of some of the clinical waste bags is not very ideal, as in paper thin, with incidents of body fluid exposure due to tears especially when the bags are very heavy.
Just a thought I have tried to look under the EPA guidelines nothing much coming up on infectious waste would be good to know what the majority are doing.- http://www.cdc.gov/vhf/ebola/hcp/medical-waste-management.html
Kind Regards
Verily Thomas
Clinical Nurse Consultant | Infection Prevention and Control
SWSLHD-Bankstown/Lidcombe Hospital
Eldridge Road, Bansktown.NSW 2200
Tel 02 97228000 pager 28230
Tel 02 9722 8633 | Fax 02 9722 7822 | verily.thomas@sswahs.nsw.gov.au
http://www.health.nsw.gov.au

[cid:image001.jpg@01CFF51E.874A6F20]
LET’S KEEP OUR HOSPITAL ENVIRONMENT CLEAN
HAND HYGIENE SAVES LIVES

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Terry Grimmond
Sent: Friday, 31 October 2014 11:51 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Ebloa Waste

Hi Sony,
I agree with you. But for countries who have harmonized with UNTDG Model Recommendations, Ebola is Category A UN2814. It is not Clinical Waste UN3291. The national law steps in and CDC and DoH recommendations are over-ruled. As happened in USA last month where DOT over-ruled CDC on this issue.
Best regards, Terry
Terry Grimmond FASM, BAgrSc, GrDpAdEd
Consultant Microbiologist
Grimmond and Associates
Ph (NZ): +64 7 855 3212
Mob (NZ): +64 274 365 140
E: terry@terrygrimmond.com
[cid:image004.png@01CFF511.A4374B10]: @terrygrimmond
W: http://terrygrimmond.com
[cid:image003.gif@01CFF50D.6D9958E0]
“This email (including any attachments) is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are reminded that any dissemination, distribution or copying of this email or attachments is prohibited. If you have received this email in error, please notify me immediately by return email or telephone and destroy the original message. Thank you.”

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Sony SO
Sent: Friday, October 31, 2014 12:58 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Ebloa Waste

Dear All,

The issue of using single clinical bag for handling infectious materials i.e. clinical waste is addressed in the CDC guidelines-Guidelines for Environmental Infection Control in Health-Care Facilities http://www.cdc.gov/~HCF_03.pdf, details are as follows:

point I, (3), page 119, which states: A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bags exterior.

Point G, (3), page 100, which states: Single bags of sufficient tensile strength are adequate for containing laundry, but leak-resistant containment is needed if the laundry is wet and capable of soaking through a cloth bag.1264

Furthermore, with reference to international guidelines related to clinical waste management(Table 1), practices of double bagging of waste is not recommended.

Lastly, practices of double-bagging of items from isolation rooms is not considered as an infection control measure, for details, please refer to:

Maki DG, Alvarado C, Hassemer C. Double-Bagging of Items from Isolation Rooms Is Unnecessary as an Infection Control Measure: A Comparative Study of Surface Contamination with Single-and Double-Bagging. Infection Control. 1986; 7(11): 535-7. Available from: http://www.jstor.org/stable/30146425

Regards,

Sony SO

Nursing Officer, Infection Control Branch (Team 2)

Centre for Health Protection

office phone: +852 2125-2922; fax: +852 3523-0752

HA email sony@ha.org.hk; DH email no_icb4@dh.gov.hk
Please consider the environment before printing this e-mail

Table 1: international guidelines for handling clinical waste

1. Biohazard Waste Industry Australia and New Zealand (BWI) (formerly ANZCWMIG). (2007). Industry Code of Practice for the Management of Clinical and Related Wastes. Retrieved 11 August 2010 from http://www.epa.sa.gov.au/xstd_files/Waste/Code%20of%20practice/Code%20of%20Practice%206th%20Edition.pdf
2. UK Department of Health. Environment and sustainability Health Technical Memorandum 07-01: Safe management of healthcare waste Retrieved August 2014 from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167976/HTM_07-01_Final.pdf
3. Uk Health & Safety Executive. (2009). Carriage of Dangerous Goods Manual-Carriage of clinical waste Retrieved 11 August 2010 from http://www.hse.gov.uk/cdg/manual/clinical/index.htm
4. World Health Organization WHO. (2008). Safe Management of Wastes from Health-Care Activities. Retrieved August 2014 from http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf
5. (2003)201410http://www.moh.gov.cn/mohyzs/s3576/200804/18353.shtml
6. (1997)(97) 201410http://wm.epa.gov.tw/medicalwaste/Documents/HandBook39all3.pdf

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Friday, October 31, 2014 5:20 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Ebloa Waste

[This message is posted on behjalf of Belinda Henderson, ACIPC President. Note that this issue has been discussed through the ACIPC Executive Council at National and State/juristictional level. ICPs are urged to check with their state/juristiction authorities and local waste contractors regarding any local impact of this issue Moderator]
We want to update our members on the issue of Ebola Waste transport in Australia. One of our members, Terry Grimmond, has been working with authorities to develop a practical, safe and legal packaging solution so we asked him to summarise where Australia is at.

Thank you Belinda,
Many ACIPC members will have seen the Oct 3 CDNA/AHPPC recommendations for double-bagging Ebola waste and transporting it as clinical waste1 (i.e. shipping as UN 3291). These recommendations are sound and evidence-based.
However, what many may not know is that the Australian Dangerous Good Code (ADG)2 requires substances known or reasonably expected to contain a Category A Infectious Substancein any form (e.g. Ebola waste) to be packaged according to ADG P620 requirements, which require:

a 95k Pa pressure-tested, leakproof primary receptacle that is sealed and placed inside a:

leakproof secondary receptacle containing absorbent material, sealed and placed inside:

a rigid outer container certified to ADG 9m drop, Rod Impact, and Water-spray tests.
The issue is, P620 packaging is designed for specimens, cultures, etc and no P620 packaging exists for large Category A items such as waste bags, mattresses, etc.
If waste companies pick up Ebola waste in anything other than P620 packaging, they would be breaking the law. Alternative packaging systems must be approved as safe as ADG P620.
Submissions need be made to the competent authority (CA) in each state (no Federal CA) and an approval in one state is not applicable in another, so multiple submissions need be made.
With the CDNA recommendation (double-bag and handle as clinical waste (CW), the medical waste firm SteriHealth saw the compliancy issue early (same occurred in USA with CDC and DOT) and retained me to work with CA to develop a triple-packaging system of equivalent safety to ADG. The Biohazard Waste Industry is also working with CA to obtain packaging approvals.
I worked with WorkCover NSW for several weeks and, after developing a leakproof sealing system for CW bags, and consultation with Westmead Hospitals IPs (Kath Dempsey, Jo Tallon), we have developed a triple-packaging system we believe is of equal safety to ADG P620. Multi-sized systems will need be approved but in this instance I submitted a system with a high chance of approval so that at least one system was available.
WorkCover NSW hope to release their decision tomorrow [31 October Moderator]. Hopefully an approval in NSW will make submissions easier and faster in other states.
Yesterday [29 October Moderator] I spoke with Prof Lyn Gilbert, Head of Ebola Task Force and Prof Chris Baggoley, Chief Medical Officer, Australian Dept of Health and they have scheduled the item for discussion this week to examine means of expediting the submission process Australia-wide.
Terry Grimmond FASM, BAgrSc, GrDpAdEd
Consultant Microbiologist, Grimmond and Associates
terry@terrygrimmond.com

1. Ebola Virus Disease (EVD). CDNA NATIONAL GUIDELINES FOR PUBLIC HEALTH UNITS 3 Oct 2014. Communicable Disease Network Authority, Australian Department of health. http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-ebola.htm/$File/EVD-SoNG.pdf.

2. The Australian Dangerous goods Code Ed 7.3(2014). http://www.ntc.gov.au/heavy-vehicles/safety/australian-dangerous-goods-code/.

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