lessons from the ebola and ebola waste crisis
DESCRIPTION
Dr. Jorge Emmanuel, environmental scientist, and medical waste consultant for the United Nations Development Programme, presented the results of his trip in Ebola hotspot areas - Guinea, Liberia and Sierra Leone, where he introduced safe alternatives to incineration that will treat and disinfect Ebola related Wastes. The event was held at a forum organized by the Philippine College of Physicians - Southern Luzon in Muntinlupa City, Philippines. The forum is part of the month-long celebration of the first Philippine Zero Waste Month declared by the Philippine government last 2014.emerging technologies on disposal of health care wastes. Presented at the Philippine Department of Environment and Natural Resources (DENR) forum celebrating the First Philippine Zero Waste Month last January 26, 2015 in Quezon City, Philippines.TRANSCRIPT
P H I L I P P I N E C O L L E G E O F P H Y S I C I A N S ( S L ) M E E T I N G A L A B A N G , P H I L I P P I N E S
2 7 J A N U A R Y 2 0 1 5
D R . J O R G E E M M A N U E L C H I E F T E C H N I C A L A D V I S O R
U N I T E D N A T I O N S D E V E L O P M E N T P R O G R A M E B O L A W A S T E P R O J E C T
P R E S E N T E D I N C O O P E R A T I O N W I T H
H E A L T H C A R E W I T H O U T H A R M
The Crisis of Ebola and Ebola-Contaminated Waste
in West Africa
Outline
Ebola Virus Epidemiology Transmission Environmental Persistence Latest Situation Report Highlights of the Ebola Crisis Ebola Emergency Response Crisis of Ebola-Contaminated Waste Waste Treatment Personal Comments
Ebola Filovirus
Ebola – one of the most virulent pathogens Family of Filoviridae Five species Zaire – responsible for various outbreaks in Central Africa and
the current epidemic in West Africa (up to 90% case fatality rate)
Sudan – outbreaks in Sudan and Uganda in the 70s and 2000s (50% case fatality rate)
Taï Forest (Ivory Coast) – one human case (survived) Bundibugyo – emerged in Uganda in 2007 (30% case fatality
rate) Reston – found in monkeys and pigs in the Philippines, mild
or asymptomatic in humans
Pathogenesis
Ebola infects macrophages and dendritic cells causing necrosis and releasing large numbers of new viral particles into extracellular fluid
Causes extensive tissue necrosis
GI dysfunction: vomiting and diarrhea results in acute volume depletion, hypotension and shock
Coagulation defects: rapid and severe coagulopathy
Pathogenesis
Incubation period: 2 to 21 days (typically 2 - 6 days)
Symptoms: Initial: Fever, fatigue, muscle pain, headaches Nausea, diarrhea, vomiting, rashes Symptoms of impaired kidney and liver function Bleeding (in some percentage of patients): oozing from the
gums, blood in stool, etc.)
Lab findings: Low WBC, platelet count Elevated liver enzymes
Diagnosis
Travel and work history to determine possible exposure
Most common diagnostic procedures in the field Real-time polymerase chain reaction to detect viral RNA Enzyme-linked immunosorbent assay to detect proteins
Other diagnostic methods Isolating virus by cell culture, identification of filovirus by
electron microscopy Detecting antibodies against the virus (for late stage patients
and survivors)
Epidemiology
Filoviruses were first recognized in 1967 Ebola Zaire species first recognized in two outbreaks in Zaire
and Sudan in 1976 (Ebola is named after a river in Zaire) Several hundred cases of ZEBOV in Kikwit, DRC, in 1995 ZEBOV first broke out in West Africa (Guinea) around
December 2013 and led to current epidemic First case – 2-year old child Sustained human-to-human transmission to major cities of
Conakry, Guinea; Monrovia, Liberia; and Freetown, Sierra Leone
Transmission
Transmission
Viral reservoir – believed to be fruit bats Secondary hosts Gorillas, chimpanzees Antelopes Pigs
Animal-to-human transmission Contact with blood and other body fluids of infected animals Food preparation of bush meat (contact with fluids, organs
and tissues of infected animals)
Transmission
Portals of entry
Mucous membranes, conjunctiva, pharynx
Skin breaks
Environmental Persistence
Laboratory studies: On solid surfaces / room T (20-25ºC) / total darkness
Dried on plastic, metal, glass / room temperature
Dried on solid surfaces, culture or sera / cold T (4ºC)
1.5 days 5.9 days
90% reduction 99.99% reduction .
46 days 99% to 99.9% reduction
No survivors when tested at
14 days
? Note: Ebola was completely inactivated sometime before 14 days but researchers did not determine when.
Note: Ebola survived longer in the cold.
Environmental Persistence
Laboratory studies: In artificial aerosols / 50-55% humidity / room T (22ºC)
Patient Care Environment during an outbreak No virus detected in bed frame, intravenous fluid support pole, light
switch, bedside chair, spit bowl, intravenous tubing Virus detected in two samples that were visibly bloody
Outside environment (direct solar radiation at noon)
15 minutes
50% reduction
1.5 hours
90% reduction . Estimate based on solar UV radiation at noon
in West Africa from November 1-16, 2014
Note: Aerosol droplets fall to the ground and do not remain suspended in air.
Note: Cleaning & disinfection in the patient care environment increases protection.
Persistence and Inactivation
Heat:
Ebola is relatively fragile
Ebola is reduced by 99.999% at 60ºC in 22 minutes
Heating to 60ºC for 1 hour gives an extra margin of safety
Boiling would inactivate Ebola
Pressurized steam (autoclaving) would destroy Ebola rapidly
Latest Situation Report
Total as of January 11, 2015 21,296 Ebola cases (mostly in Guinea, Liberia, Sierra Leone) 8,429 deaths
Latest Situation Report
Highlights of the Ebola Crisis
Mysterious illness – initially thought to be malaria Even doctors and nurses familiar with hemorrhagic
fevers did not have sufficient PPE Doctors, nurses, nurses aides, ambulance drivers,
and burial workers started dying As of December, 570 doctors, nurses, health workers have died Sierra Leone only had 95 doctors and 991 nurses nationwide
Highlights of the Ebola Crisis
Rise of deadly myths and rumors Government-created crisis to get economic aid Foreigners were bringing this mysterious disease Patients taken to Ebola Treatment Units come out in body
bags
Highlights of the Ebola Crisis
Ebola moves into the major densely populated cities Hiding of Ebola-infected persons in communities Mass quarantines Attacks against health workers and Ebola Treatment
Centers
Highlights of the Ebola Crisis
People started dying in the streets in major cities Hospitals and clinics treating Ebola patients were
overwhelmed – some driven away, others on the floor All schools and businesses shut down, economy ground to a
halt
Highlights of the Ebola Crisis
Entire communities were wiped out One town alone in Sierra Leone has 1,455 orphans
Highlights of the Ebola Crisis
No international help came except for Doctors Without Borders and a few private groups working with the local health workers
The world ignored cries for help from the Ebola-affected countries
Ebola Emergency Response
Creation of national Ebola command centers Community education “Ebola is not a death sentence. Early treatment saves lives” Symptoms of Ebola Virus Disease Do not eat bush meat. Do not touch body fluids of infected persons. Do not touch the body of person who died of Ebola.
Ebola Emergency Response
Provision of PPE and disinfectants Universal Precautions for Infection Prevention
Ebola Emergency Response
Contact Tracing Containment: Isolation of Suspected Cases Creations of ETUs
Intensive Care Management of symptoms Rehydration Septic shock management
Psycho-social support
Crisis of Ebola-Infected Waste
No sharps waste management
Crisis of Ebola-Infected Waste
Improper storage of infected waste
Crisis of Ebola-Infected Waste
Overflowing waste pits
Waste Treatment
Health impacts of burn barrels
Waste Treatment
Problems with the incinerators PPE has a seam coating that melts at 98°C PPE has flash ignition point of 343°C PPE material has a heat release capacity of about
1560 J/g-K self-sustaining combustion PPE has a heating value of 46.3 MJ/kg (same as gasoline)
Waste Treatment
Problems with the incinerators Heavy black smoke and high levels of HCl and dioxins Ebola patients in wards some as near as 4 meters exposed
to high levels of PM10, CO, HCl and other toxic pollutants Strong opposition by nearby communities No technical support provided
Europe: 62% of dioxin emissions due to 4 processes, including MWI
Belgium: MWI accounts for 14% of dioxin emissions Denmark: MWI is 3rd or 4th largest dioxin source of 16 process
groups Thailand:
MWI - highest dioxin source by far of 7 sources tested Extremely high dioxin levels in MWI ash and wastewater
United States: MWIs – third largest source of dioxins: 17% of total dioxins in
1995 Drop in dioxin emissions from MWI in part due to shift to non-
incineration methods: 2470 g TEQ/yr in 1987 to 477 g TEQ/yr in 1995
Canada: MWI - largest dioxin source in Ontario province Drop in dioxin emissions from MWI due to closure of MWIs:
130 g TEQ/yr in 1990 to 25 g TEQ/yr in 1999
Waste Treatment and Dioxins
Waste Treatment and Dioxins
Short term for polychlorinated dibenzo-p-dioxins and dibenzofurans
Family of 210 compounds Among the most toxic compounds known to
humans > The most toxic is
2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)
Environmental half-life on surface soil: 9 to 15 years
Environmental half-life in subsurface soil: 25 to 100 years
Volatilization half-life in a body of water: more than 50 years
Waste Treatment and Dioxins
Classified as a known human carcinogen by IARC in 1997
Cancers linked to dioxins: Chronic lymphocytic leukemia (CLL) Soft-tissue sarcoma Non-Hodgkin’s lymphoma Respiratory cancer (of lung and
bronchus, larynx, and trachea) Prostate cancer
Waste Treatment and Dioxins
Developmental Effects Birth defects Alteration in reproductive systems Impact on child’s learning ability and attention Changes in sex ratio (fewer male births)
Immune System Impacts Suppression of the immune system Increased susceptibility to disease
Male and Female Reproductive Effects
Waste Treatment and Dioxins
STUDY SUBJECTS
CONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS
REFERENCE
Residents living within 10 km of an incinerator, refinery, and waste disposal site
Significant increase in laryngeal cancer in men living with closer proximity to the incinerator and other pollution sources
P. Michelozzi et al., Occup. Environ. Med., 55, 611-615 (1998)
532 males working at two incinerators from 1962-1992
Significantly higher gastric cancer mortality
E. Rapiti et al., Am. J. Ind. Medicine, 31, 659-661 (1997)
Residents living around an incinerator and other pollution sources
Significant increase in lung cancer related specifically to the incinerator
A. Biggeri et al. Environ. Health Perspect., 104, 750-754 (1996)
People living within 7.5 km of 72 incinerators
Risks of all cancers and specifically of stomach, colorectal, liver, and lung cancer increased with closer proximity to incinerators
P. Elliott et al., Br. J. Cancer, 73, 702-710 (1996)
Waste Treatment and Incineration
STUDY SUBJECTS
CONCLUSIONS REGARDING ADVERSE HEALTH EFFECTS
REFERENCE
122 workers at an industrial incinerator
Higher levels of lead, cadmium, and toluene in the blood, and higher levels of tetrachlorophenols and arsenic in urine
R. Wrbitzky et al., Int. Arch. Occup. Environ. Health, 68, 13-21 (1995) 176 incinerator workers
employed for more than a year from 1920-1985
Excessive deaths from ischemic heart disease and lung cancer among workers employed for at least 1 year; significant increase in deaths from ischemic heart disease among workers employed for more than 30 years or followed up for more than 40 years
P. Gustavsson, Am. J. Ind. Medicine, 15, 129-137 (1989)
Mothers living close to incinerators and crematoria in Cumbria, England, from 1956 to 1993
Increased risk of lethal congenital anomaly, in particular, spina bifida and heart defects around incinerators, and increased risk of stillbirths and anacephalus around crematoria
T. Drummer, H. Dickinson and L. Parker, Journal of Epidemiological and Community Health, 57, 456-461 (2003)
Waste Treatment and Incineration
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1984 2002
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Waste Treatment and Incineration (MWI)
Germany Portugal
Ireland
United States Canada
Treatment technologies Autoclaves- various sizes Autoclaves with shredders Hybrid autoclaves Continuous steam treatment systems Batch microwave units Continuous microwave units Frictional heating units
Non-Incineration Waste Treatment
Crisis of Ebola-Infected Waste
My previous work
Ebola is destroyed by autoclaving in seconds Technology built by Africans for Africa No smoke, no dioxins nor HCl, no toxic air pollutants Safe for workers with PPE Special barrel trolley protects workers from Ebola exposure Uses mechanical controls instead of computer controls –
easier to fix Rides through power outages that are common in Africa Uses steam ejectors instead of vacuum pumps – less
maintenance problems, waste volume reduced by 40-60% Installs in one day, cheaper than an incinerator Exceeded international standards by an order of magnitude
Waste Treatment
Personal Comments
Personal Comments
Personal Comments
Personal Comments
Ebola cases are beginning to decrease in West Africa
Work is now shifting towards recovery The danger of Ebola should not be used as an
excuse to bring back incineration Autoclaves are effective in dealing with Ebola
and other infectious wastes while avoiding the environmental health problems and cost of incineration