Table 1. Summary of the Hazard Analysis of Critical Control Point (HACCP) assessment for the disposal of waste potentially contaminated with Ebola virus.
| Potential hazard by critical control point | Level of concern about contaminated materials |
Recommendationsb | |
|---|---|---|---|
| with blood | with bodily fluids other than blooda | ||
| 1. Latrine use | |||
| Contamination of environment | High | Medium | – Suspected and confirmed cases use isolated and segregated latrines and keep pit secure for 7 days10,24 after last use by suspected case. – Avoid surface water inflow by using external channels or concrete surroundings, and ensure adequate quality of construction to limit risk of collapse and contamination of groundwater sources.17 – Using a single-use cloth – which should subsequently be incinerated – clean surfaces with water and detergent. Then wipe 0.5% chlorine solution16,18–21 over all surfaces, including door handles, toilet seat, floor and walls.7 – Wash hands with soap and water after using latrine. |
| 2. Washing and cleaning | |||
| Contamination of cleaner | High | Medium | – Provide proper training of cleaners and ensure experienced supervision. – Use water and detergent for cleaning, followed by 0.5% chlorinated water for disinfecting.10,18,19 – Treat wastewater as per CCP12. |
| 3. Reuse or shared use of fomite | |||
| Inadequate cleaning | High | Medium | – Avoid reuse where possible and dispose as per CCP8. If reuse is essential, wear full PPE when washing reusable materials or products.c – Check fomite for damage and suitability for reuse. If reuse is possible, clean fomite using a moist single-use cloth, which should then be incinerated. Following cleaning, if possible, with a wash with water at > 60 °C.16,22 If not possible, soak in 0.5% chlorine solution18,19 for a minimum of 30 min, after removing most organic material, 10,16,21,22 and then let air-dry before transporting for reuse. |
| 4. Transport | |||
| Splashing on handler | High | Medium | – Avoid handling fresh waste. If unavoidable, wear full PPE and employ appropriate hand hygiene measures.c |
| Contamination of vehicles and/or containers | High | Medium | – At end of each transportation or shift, using a moist single-use cloth that should subsequently be incinerated, clean vehicles and containers with water and detergent. Following cleaning, disinfect using 0.5% chlorine solution.16,18,19,21 If cloth must be reused, wash with warm water and detergent while wearing appropriate PPE to remove organic matter. Then soak in 0.5% chlorine solution for a minimum of 30 min and rinse with cold water. 23 – Always wear full PPE when cleaning vehicles and containers and disinfect or burn PPE after use. |
| Contamination of environment | Medium | Low | – Use leak-proof containers – e.g. plastic barrels with secure lids – for contaminated items.17 – Using a single-use cloth that should subsequently be incinerated, clean outer surfaces of vehicles and containers before and after use with water and detergent. If cloth must be reused, wash with warm water and detergent, while wearing appropriate PPE, to remove organic matter. Then soak in 0.5% chlorine solution for a minimum of 30 min and rinse with cold water.23 Following cleaning, disinfect using 0.5% chlorine solution. 10,18,19,21 – Enclose and/or isolate site. – Spills should be covered first with a cloth, to avoid splashing or dispersion of fluids. Then wipe up spill with rags and dispose of rags through incineration. Clean the area with a detergent and water and then disinfect by wiping with 0.5% chlorine solution. 18,19 |
| 5. Disposal of sharps | |||
| Contamination of handler | High | Low | – Sharps should be segregated from other waste at point of generation, 17,21,23 placed in puncture-resistant, sealed biohazard-labelled containers and disposed of appropriately, as local facilities allow. 17,23 |
| 6. Emptying of latrine when more than two thirds full | |||
| Contamination of handler | Variable, depending on age of waste, construction of latrine etc. | Variable, depending on age of waste, construction of latrine etc. | – Wait a minimum of 7 days after last use by a known case before desludging. 19,24 – If not possible to wait 7 days, wear full PPE. 25–27,b |
| 7. Storage | |||
| Exposure to contaminated waste | Variable, depending on age of waste | Variable, depending on age of waste | – Segregate waste into a secure nonporous container and destroy within 24 h.19 |
| 8. Burning of waste | |||
| Incomplete combustion | Low | Low | – If waste is to be burned, use an incinerator – that reaches sufficient complete burning temperatures and meets environmental emission standards – according to manufacturer’s operating manual. If an incinerator is not available, burn in a barrel or pit with sufficient additional combustible material to ensure complete combustion.19 – If large volumes of waste need to be burned, divide into smaller volumes before burning.19 – PPE should be worn but extreme caution needs to be taken to avoid the handler’s PPE catching alight. |
| 9. Cleaning and disinfecting of non-human waste | |||
| Theft and reuse | Low | Low | – For fabric waste – e.g. bed linen and clothing – discard if possible. If reuse necessary, wash with warm water and detergent, while wearing appropriate PPE, to remove organic matter. Then soak in 0.5% chlorine solution for a minimum of 30 min and rinse with cold water. – For hard waste – e.g. crockery and buckets – wash with a detergent, while wearing appropriate PPE, to remove organic matter. Then soak in 0.5% chlorine solution for a minimum of 10 min and rinse with cold water. – Items can be reused if not damaged. For items not suitable for reuse, dump in a secure area and limit animal access to the secure area. 10,16,18,19,21 |
| 10. Burial of waste | |||
| Digging up or theft of health-care waste | Low | Low | – Bury in reliably secure areas, with limited access to animals, and keep secure for 14 days after last disposal. – Acidify or soak in 0.5% chlorine solution for 30 min10,16,18,19,21 before dumping. |
| 11. Disposal on ground | |||
| Contamination of food crops | Low | Low13 | – Prevent disposal onto ground used for food crops and ensure that all crops are handled and prepared according to appropriate food safety guidelines.28 |
| Contamination of water supply | Low | Low | – Ensure water supply point is designed to prevent contamination following principles of sanitary assessments included in water safety plans.12 – Encourage safe water handling and storage practices and encourage proven household water treatment methods – e.g. filtration, chlorination or boiling.12,19 |
| 12. Discharge and treatment of wastewater through sewer | |||
| Contact of general public with virus via open sewers | Low | Low | – Give public health education to community representatives and construct physical barriers.12 Ensure appropriate conditions of carriage – in many places effluent streams are used by neighbours17 – by following sanitation safety planning guidelines.17,29 |
| Contact of sewage workers with virus | Low | Low | - Ensure standard PPE and hygiene practices are followed.30 |
| 13. Open defecation | |||
| Human and animal contact with virus via human excrement | Low | Low | – Discourage open defecation and encourage pit latrine use. Remove excrement to a pit latrine or bury at a minimum depth of 0.5 m. If unavoidable, dump excrement in secure area. |
CCP: critical control point; PPE: personal protective equipment.
a Including urine, faeces and wash water.
b During the execution of this recommendation, appropriate hand hygiene must be employed and full PPE worn, with the correct protocols observed. After each use, PPE should be treated as an infected fomite and either disinfected or burned.
c Due to the nature of Ebola viruses, there must be 100% compliance with this recommendation.