Lessons From the Ebola and Ebola Waste Crisis

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

http://en.wikipedia.org/wiki/File:Symptoms_of_ebola.png

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


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


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


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


Entire communities were wiped out One town alone in Sierra Leone has 1,455 orphans


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.


Provision of PPE and disinfectants Universal Precautions for Infection Prevention


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


Improper storage of 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


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


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


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


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

554

00

200

400

600

1984 2002

On

-Sit

e M

WIs

150

00

50

100

150

200

1990s 2005

MW

Is

40

10

1020304050

1995 2004M

WIs

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


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

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

Lessons From the Ebola and Ebola Waste Crisis

Documents

Transcript of Lessons From the Ebola and Ebola Waste Crisis