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VOL. XI NO. 1

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JAn-MAR 2015

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Emergency Preparedness:

Reconsidering On-site Disposal Options

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By Alice P. Jacobsohn

hen hospital and emergency responders are asked about emergency preparedness, the talk immediately turns to the possibility of a surge in the number of patients affected by disasters external to their facilities such as earthquakes, terrorist attacks, or epidemics.

Some responders consider the management of patients when the hospital is located in a disaster area and becomes damaged such as flooding or loss of electricity caused by a hurricane. Often, patient care is where emergency preparedness stops. With the recent Ebola outbreak, we are finding very little preparedness for highly infectious waste, struggling with gaps in available disposal technology.

“There is a range of preparedness at hospitals, but we need to pre-designate facilities to handle specialized diseases,” said Darrell Henry, Executive Director, Healthcare Coalition for Emergency Preparedness,

Washington, DC. He added, “These centers should have on-site sterilization technology.”

Henry is not alone in emphasizing onsite treatment options. The World Health Organization issued guidance in December 2014, stating, “It is not recommended to transport untreated infectious waste and therefore all waste should be treated on-site” According to the Centers for Disease Control and Prevention (CDC), as of February 13, 2015, there are 55 hospitals prepared to handle Ebola patients. These are located in 18 states and Washington, DC. The minimum requirements for this designation include securing the services of a waste management company capable of managing and transporting Category A waste, the classification adopted by the U.S. Department of Transportation (DOT) that includes Ebola waste. The designation requirements do not mention on-site disposal Continued on page 3

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Healthcare Environmental Solutions news

solutions PUBLICATION STAFF Publisher / Editor Rick Downing Contributing Editors / Writers Alice P. Jacobsohn Sandy Woodthorpe Production & Layout Barb Fontanelle Christine Pavelka Advertising Sales Rick Downing Subscription / Circulation Donna Downing Editorial, Circulation & Advertising Office 6075 Hopkins Road Mentor, OH 44060 Ph: 440-257-6453 Fax: 440-257-6459 Email: downassoc2@oh.rr.com For subscription information, please call 440-257-6453.

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Emergency Preparedness:

Reconsidering On-site Disposal Options Continued from page 1

technology capabilities, although this is an option.

For most hospital decision-makers focused on keeping their institution’s in the black, spending resources on emergency preparedness lacks the appeal of robotic operating rooms and the latest technology to zap away cancer cells.

Even when considering emergency preparedness, waste disposal options take second seat to the costs of isolation rooms and training of doctors and nurses.

Why should a hospital invest in emergency response and infectious waste disposal especially when there have been so few cases of Ebola or any other exotic diseases recently in the United States?

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enry responded, “While the daily risk is low, the potential is very high.” People do not select a hospital because of the facility’s waste disposal operations, but Henry says, “If people lose confidence in a hospital, they won’t get treated. We need to avoid creating a public health crisis.”

The situation at Texas Health Presbyterian Hospital in Dallas last October when two nurses became ill after treating an Ebola patient and where waste was shipped to a Port Arthur, Texas incinerator 325 miles away, raises the concern about public confidence and waste disposal options. According to hospital officials, Bellevue Hospital in New York City spent about $100,000 a day on waste disposal from one patient. This is compared to national disposal averages of between 18 and 50 cents per pound of medical waste with two to eight pounds per patient generated daily.

Henry’s coalition recommends a different approach to justifying emergency preparedness with on-site disposal methods. He said, “You have to look at the cost-benefit analysis and integrate emergency preparedness with daily operations.” This approach is different because rather than look at how to fund an emergency system that may never be needed, a hospital is spending the money required to manage the waste it generates every day and ensuring that the daily program can address a spike in loads should an emergency occur.

When the medical waste disposal company at Emory University Hospital in Atlanta last fall refused to accept Ebola-contaminated waste, the hospital borrowed a large, high-pressure autoclave from its university to treat the 40 bags of Ebola waste generated each day. Nebraska Medical Center in Omaha is likely the most prepared facility with an on-site biocontainment unit, but even after sending the waste through its autoclave, that waste was re-bagged and managed as regulated medical waste. jan-mar 2015

Why are on-site disposal methods lacking?

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he first time that infectious waste was formally recognized as a waste stream was in 1978, when the U.S. Congress through Subtitle C of the Resource Conservation and Recovery Act included “infectious” as a criterion to consider for hazardous waste regulation. However, when the U.S. Environmental Protection Agency (EPA) developed the associated regulations in 1980, infectious waste management was not included. After medical waste washed up on New Jersey beaches in the early 1980s, Congress passed the Medical Waste Tracking Act creating a pilot program for regulation of infectious waste. The pilot program ended in 1991 with EPA deciding not to regulate. In the meantime, in 1987, the CDC issued recommendations on infectious waste management in its universal precautions guidance. By 1989, 84 percent of states were regulating medical waste. Other agencies such as the Occupational Safety and Health Administration and the DOT also began regulating medical waste in the 1980s.

Because of all these agencies’ activities regarding medical waste management, hospitals began seeking treatment and disposal options. At that time, very few off-site options were available. Therefore, hospitals installed incinerators, the available disposal method in the 1980s. A report to Congress by the Office of Technology Assessment, found that in 1988, 80 percent of hospital medical waste was incinerated.

This all changed when Congress passed the Clean Air Act over health concerns from air emissions. The law required EPA to regulate major pollutant sources, including medical waste incinerators. In 1997, when EPA promulgated final standards, the agency reported that 2,400 incinerators existed. In 2009, when EPA issued new standards, only 22 commercial incinerators were left and most of these were not located onsite at hospitals.

“Many hospitals tried to upgrade their incinerators to comply with the new requirements,” said Arthur McCoy, Senior Vice President, San-I-Pak World Health Systems, Tracy, California. He added, “Hospitals spent millions of dollars and their incinerators still failed to meet the standards so they became gun shy about spending more money for on-site treatment. The incinerators were removed and transporters were hired as an interim measure, but then transporting became permanent.”

Today, only 20 percent of hospitals house on-site options and many of these are not large enough to handle the volumes of waste from Ebola patients. The other 80 percent of hospitals contract with a medical waste hauling company Continued on page 4

HEALTHCARE ENVIRONMENTAL SOLUTIONS news

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Healthcare Environmental Solutions news

Emergency Preparedness:

Reconsidering On-site Disposal Options Continued from page 3

to carry containerized waste to state-permitted disposal facilities. Ninetyfive percent of medical waste is autoclaved, but this number is changing with other technologies on the market. These include ozone systems, plasma arc methods, pyrolysis, microwaves, chemical treatments, and electron-beam technology.

In an ozone disposal system waste is shredded and then treated with high levels of ozone killing the pathogens. Ozone is considered a natural sterilization agent. The process does not involve heat. Hancock Regional Hospital in Greenfield, Indiana is operating an ozone system, as is Union Hospital in Terre Haute, Indiana. Other commercial units are located in Aurora, Colorado and Indio, California.

In plasma arc technology, instead of burning the waste like an incinerator, the waste is heated to a much higher temperature such that the waste melts and then vaporizes. This is done by an electrical device known as a plasma arc, which is a kind of super-hot torch made by passing gas through an electrical spark. The technology has mostly been used for metal cutting and treating sewage sludge.

Pyrolysis is a gasification process that uses heat in the absence of oxygen. Unlike traditional incineration, the flame never touches the waste and no outside air is added to the chamber, thus the waste does not combust and create air emissions and particulate matter. Several units are operational in the U.S. in California and Hawaii. A company from the United Kingdom sent a unit to West Africa to help manage Ebola waste.

Microwaves refers to electromagnetic energy having a frequency higher than 1 gigahertz (billions of cycles per second), corresponding to wavelengths shorter than 30 centimeters. Waste is shredded and high temperature steam is added and then the waste is subjected to electromagnetic energy destroying the pathogens. A number of units are commercially available in the U.S. The first unit was installed in 1990 at Forsyth Memorial Hospital in Winston-Salem, North Carolina.

Chemical treatments are mostly used as disinfectants on hard surfaces.

Some of the Ebola waste management guidance, issued by state and federal agencies, recommend adding bleach to medical waste going off-site as a means of reducing risk. A commercial-size medical waste disposal unit was installed at Blue Mountain Hospital in Salt Lake City, Utah.

Electron-beam processing involves exposing the waste to a stream of high energy (fast) electrons that are attracted back to positive ions, causing a chemical reaction that kills the infectious substances. An electron-beam system is located at the Laboratories for Pollution Control Technologies at the University of Miami, in Florida, and in partnership with Jackson Memorial Medical Center.

Most of the 55 designated Ebola centers use off-site treatment. “I do know that waste disposal for Ebola-related cases, suspected or otherwise, is done off-site,” stated Lorna Wong, Director, Media Relations and News Office, in describing the process for the University of Chicago Medicine and Biological Sciences Center, Chicago, Illinois. According to the New York Department of Environmental Conservation, all of the designated New York City hospitals have off-site disposal arrangements.

Most of the outsourced services for hospital medical waste management are for Category B or regulated medical waste and do not cover Category A materials. For hospitals that have commercial-size onsite disposal technology, the majority made purchase decisions based on managing Category B waste. For those states issuing their own disposal facility guidance or regulations, separate permission is often required to accept Category A waste. Regardless of regulatory requirements and on-site or off-site arrangements, disposal technology should be tested to manage Category A waste if the equipment will be used for that purpose.

Since the first cases of Ebola patients in the U.S., the DOT issued an advisory on transportation requirements associated with Ebola waste.

The advisory directs the regulated community to existing regulations 4

HEALTHCARE ENVIRONMENTAL SOLUTIONS news

jan-mar 2015

“The initial confusion and subsequent progress made on the management of Ebola-contaminated waste should serve as a wake-up call for hospitals to reassess their waste disposal options.” for Category A materials that require more stringent packaging than regulated medical waste. These regulations apply to transport in non-bulk packaging. To date, only ten companies have received a special permit for transporting Ebola-contaminated waste in large packaging. Some of these permits will expire at the end of March 2015 if not renewed.

“I believe that on-site treatment will increase in the future because it is cheaper to manage waste that way,” said McCoy. He added, “I don’t say that on-site is better because I am a vendor. We have shown that onsite disposal is 70 percent cheaper than off-site disposal. I encourage any hospital looking at options to visit a hospital with an on-site system to see for themselves.”

McCoy described what a hospital should do to make a decision on waste management. He indicated, “The first step in the process is to perform a complete survey of the hospital for all waste streams -- solid, medical, and hazardous. This survey includes measuring upfront capital investment, labor, utilities, maintenance, consumables such as autoclave bags and liners, and landfill costs. Step two is a survey of the area, engineering work, to see how the technology will fit into the hospital’s space. And step three is to design a unit to fit the space and the needs of the hospital.”

These steps imply a careful analysis of material handling systems at a hospital both to reduce the total waste generated and to minimize the risk of exposure. McCoy and Henry agree that risk of liability is a huge factor in a hospital’s decision. “A hospital never relinquishes its liability for medical waste even when outsourcing,” said Henry. This is in reference to federal transportation regulations that hold the shipper or generator responsible until the final disposal site accepts the waste. “A hospital can reduce its risk by eliminating artificial transfer to a transporter with onsite management,” said McCoy. The initial confusion and subsequent progress made on the management of Ebola-contaminated waste should serve as a wake-up call for hospitals to reassess their waste disposal options. Since EPA shut down most of the hospital waste incinerators, emerging diseases have increased, creating a gap in our knowledge of best practices for waste management. The available medical waste disposal technologies may be effective, but were originally designed to manage normal, daily loads.

Many of these technologies will work well as part of an integrated waste management system that considers all hospital waste streams.

Alice P. Jacobsohn is a government relations leader and attorney with a focus on assisting industry in understanding regulatory requirements, participating in the legislative and regulatory process, and positioning themselves for growth. She can be reached at alicej5251@gmail.com.

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HEALTHCARE ENVIRONMENTAL SOLUTIONS news3:175PM 1/22/15

News Briefs

Ebola Case Spurs New Medical Waste Legislation in Texas

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ustin, TX – State senators say proposed rules on storing and transporting medical waste can help prepare Texas for future infectious diseases, according to a report on KXAN.com.

The draft legislation spells out powers of government, law enforcement authorities and public health officials in the event of possible contagious disease outbreaks. The provisions of the proposed law allow the governor to declare an infectious disease emergency and police to detain individuals under a “control order” for up to 48 hours. Also, the State Department of Health can impose immediate quarantine enforcement and halt transportation carriers to obtain more information on exposed or infected individuals. Rules for testing of pets and livestock that may have become infected are described as well.

Senate Bill 538 grew out of the recommendations of a special task force Texas formed after Liberian visitor Thomas Duncan was diagnosed with Ebola at a Dallas hospital.

Other provisions of the bill build on steps the state took immediately in September 2015, such as designating specific hospitals equipped for the treatment and care of patients with infection disease. The bill provides for stockpiling of protective gear, educating first-responders on how to cope with infectious patients and evaluating new technology for tracking exposed individuals.

Under current law, Texas’ health commissioner can issue “control orders” restricting the travel and movement of people infected with, or at risk of spreading, infectious diseases. The new bill clearly addresses how officials handle violations of those orders.

The bill was introduced by Senator Charles Schwertner and authored by eight other state senators.

Ebola Virus Remains Transmittable for Seven Days Post Mortem

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ethesda, MD – The Ebola virus could remain infectious in cadavers for at least seven days after death, National Institutes of Health (NIH) scientists have found, reports ScienceDaily.com.

To conduct the study, scientists at NIH’s National Institute of Allergy and Infectious Diseases used oral swabbing methods to sample deceased Ebola-infected monkeys that were placed in a chamber to mimic environmental conditions in West Africa.

Live virus was detectable in surface swabs up to seven days after death, and in the tissue samples, up to three days post-mortem. Viral RNA was detectable in several swab and tissue types for up to 10 weeks.

The research showed that oral swabbing of bodies as a reliable and safer alternative to riskier procedures for obtaining diagnostic samples.

The practice also underscores the importance of using safe practices for handling corpses.

In addition to the oral swabbing, the scientists performed necropsies on the monkeys, sampling seven different body surfaces and removing tissue from four internal organs. This allowed the scientists to measure the amount of live Ebola virus and viral RNA, and compare test results at various time intervals.

The scientists believe these findings are likely to be consistent for nonhuman primates such as gorillas and monkeys. In fact, they designed the study to test animals found dead in the wild, but shifted the timing and emphasis to study the human implications related to the ongoing West Africa Ebola outbreak.

The study findings were published in Emerging Infectious Diseases.

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News Briefs

UCLA CRE Outbreak Highlights Infection Control Challenges

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os Angeles, CA – According to KaiserHealthNews.org, a bacterial outbreak at a Los Angeles hospital has brought the challenges of controlling antibiotic resistant infections into sharp focus.

Infection control experts say the federal government’s efforts are hobbled by gaps in monitoring the prevalence of these germs within hospitals and beyond. The continued overuse of antibiotics — due to over-prescription by doctors, patients’ insistence and the widespread use in animals and crops — has helped these bacteria evolve into more dangerous forms and flourish.

In the outbreak at UCLA’s Ronald Reagan Medical Center, two patients died and more than 100 may have been exposed to carbapenemresistant Enterobacteriaceae, or CRE, an antibiotic-resistant bacteria commonly found in the digestive tract. When this germ reaches the bloodstream, fatality rates are 40 percent. The government estimates about 9,000 infections, leading to 600 deaths, are caused each year by CRE. UCLA Health says the infections probably were spread by inadequately sterilized medical devices. Previous CRE outbreaks have occurred elsewhere in the country, including hospitals in Illinois and Seattle.

The immediate public health response targeted the duodenocopes and tracking down people who may have been exposed. The U.S. Food and Drug Administration issued a warning about the devices. The California outbreak occurred amid the government’s broader struggle to spot and battle an increasing number of bacteria strains that are resistant to most, if not all, antibiotics.

CRE is one of three infectious agents that the Centers for Disease Control and Prevention categorized as the drug-resistant threats that require the most urgent monitoring and prevention. CRE is resistant to almost all antibiotics, including carbapenems, which doctors often use as a last resort. A CDC report found that in the first six months of 2012, nearly 5 percent of hospitals reported at least one CRE infection.

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News Briefs

RedAway Receives Approval for Texas Waste Facility

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ansfield, TX – The Texas Commission on Environmental Quality (TCEQ) has granted preliminary approval to Dallas-based RedAway LLC to operate a medical waste treatment facility in the Dallas-Ft. Worth area, reports nbcdfw.com.

The Mansfield plant would treat medical waste using a steam process in a high vacuum/high pressure autoclave. Waste would consist of medical instruments, surgical gloves and gowns, and blood products, according to RedAWay’s application to the TCEQ. In addition, some of the medical waste would be stored in refrigeration units pending later transportation to a state-authorized processing or disposal facility. No waste discharge structures are included in the site plan, nor would waste disposal activities be conducted onsite.

RedAway would hire a minimum of two employees for the facility: an operations director to ensure conformance with the plant’s design and operational standards, and one operator.

Despite the site’s heavy industry zoning designation, the town’s mayor and a group of local citizens have balked at the location for being too close to several schools and subdivisions. RedAway’s application says that plant traffic is not expected to exceed 50 vehicles per day.

City leaders who have been in contact with RedAway say they are urging the company to find a different location in Mansfield for the facility.

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ew Brunswick, Canada – Firefighters spent twelve hours putting out flames at Stericycle Canada’s Moncton facility on February 28, a Metronews.ca article reports.

According to the Moncton Fire Department, the size of the blaze prevented firefighters from entering the building, which is located in an industrial park. Once the fire was brought under control, foam was applied to hot areas.

All employees who were inside the building when the fire began evacuated to safety and no injuries were reported. The cause of the fire was unknown at press time and an investigation by Environment Canada is underway.

CentraState, Gunderson Set High Standards for Sustainability

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Fire Destroys Stericycle Waste Facility in Canada

jan-mar 2015

aCross, WI – Two healthcare systems participating in the US Department of Energy’s Hospital Energy Alliance program have made giant strides in sustainable energy and waste management, according to SustainableBusiness.com.

In Freehold, New Jersey, Torcon Energy Services and KDC Solar completed Centra State Medical Center’s 6.3 megawatt solar power system last October. More than 21,408 ground-mounted solar panels on 26 acres of land are supplying electricity. KDC Solar maintains the arrays and sells the power to the hospital. CentraState serves 14,000 inpatients and 250,000 outpatient visits a year.

In Wisconsin, Gundersen Health System – a La Crosse-based network with hospitals, medical clinics and nursing homes throughout Wisconsin and parts of Minnesota, has become the nation’s first net-zero energy health system. The system is making more energy than it consumes.

Gunderson achieved a high level of sustainability through waste reduction programs, as well as a mix of energy sources: biogas, methane, woodchips, geothermal, solar and wind power. According to an announcement, the health system states its energy consumption is down 40 percent, saving $2 million a year.

Gunderson earns $2 million by selling the electricity and byproducts of biogas production.

The system used $30 million of its own money and $11 million in state and federal grants to reach net zero status.

The DOE’s Hospital Energy Alliance is an industry-led partnership that was launched in 2009 to guide energy efficiency and spearhead the use of renewables.

News Briefs

County Planning Commission Approves Medical Waste Transfer Station in Virginia

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ichmond, VA – Despite objections by neighbors, a new medical waste transfer facility has received a conditional use permit from the County Board of Supervisors here, reports a ChesterfieldObserver. com article.

The facility, to be located in Chesterfield County, will store medical waste temporarily until it’s picked up and shipped to Roanoke. Operated

by Virginia Health Care Waste Management Cooperative Inc., the facility is not intended for long-term medical waste storage. The company’s zoning application allows the waste to remain on-site for up to 72-hours, but Virginia Health has assured the community that it will be transferring the containers more frequently.

Medical waste going to the facility will consist of cultures from laboratories, needles, a very small amount of anatomical waste and bloody gauze. No nuclear or hazardous waste would be involved. The waste will be collected from hospitals, medical offices, nursing homes and laboratories around the Richmond area.

Since the facility was first proposed to the county government, neighbors have expressed concerns. To address their fears about spillage, Virginia Health says it will transfer the plastic medical waste containers from trucks to a trailer inside the building via a rear loading dock, thus preventing waste from being exposed to the elements. In addition, the company has agreed to seal the building’s concrete floor to prevent the seepage of blood or bodily fluids in the event of a spill.

Due to the staggered delivery schedule, the facility will be unattended for four to five hours at a time, another concern of the local residents. To address this issue, Virginia Health has agreed to install security fences and cameras. In compliance with zoning codes, Virginia Health will submit an emergency management plan to the county every two years.

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Research on Human Waste Results in Useful Applications

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oston, MA – From fertilizer to infectious disease, the uses for human saliva, urine, and feces are starting to multiply, reports a BostonGlobe.com article.

For example, one Vermont outfit, the Rich Earth Institute, collects human urine to sell to farmers as a nitrogen-rich soil amendment.

Volunteers donated more than 5,500 gallons of urine last year to make into fertilizer for hayfields. The Institute provides donors with containers that have odor-concealing lids and “decorative sleeves” to disguise the contents. Donors are instructed to drop off the containers at the institute’s “urine depot.”

At Boston University, a researcher is testing human saliva to isolate enzymes. She hopes to understand gluten intolerance and come up with a new treatment for celiac disease. Massachusetts also has the nation’s first “stool bank,” OpenBiome, which collects feces to be used in treating an antibiotic-resistant gastrointestinal infection caused by Clostridium difficile.

Donors for these projects are recruited from various places. About 200 volunteers from the community donate to the Rich Earth Institute’s “pee-cycling” program. OpenBiome gets its fecal donations from nearby Tufts University. The feces volunteers rigorously screened, and they are paid $40 per delivery. OpenBiome is expanding its donor pool from 14 to 40.

To obtain saliva specimens, the celiac disease researchers say they set up a booth at Boston’s Museum of Science on Fridays outside the “Living Laboratory” exhibit. More than 800 samples were collected in January.

Medicare HAC Crackdown Results in $373 million in Penalties

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jan-mar 2015

ashington, D.C. – Medicare is cutting payments to 721 hospitals nationwide for failure to control healthcare-associated infections and other complications, reports Medscape.com (Kaiser Health News).

Medicare’s actions, which are based on the findings of a study conducted by the Agency for Healthcare Research and Quality (AHRQ), affect one out of every seven hospitals in the United States. The reductions in payments are actually penalties that are mandated by the Affordable Care Act (ACA). The penalty scheme consists of lowering payments by one percent over the fiscal year beginning October 1, 2014 through September 2015. About half of the institutions affected are teaching hospitals.

AHRQ focused on three areas found to have the highest rates of “hospital acquired conditions,” or HACs: central line-associated bloodstream infections, catheter-associated urinary tract infections and serious complications, such as falls, blood clots and bed sores. Hospitals were scored on a 10-point scale. Those in the top quarter — with a total score above seven — were penalized.

The crackdown is part of Medicare’s aim to reduce complications that are considered avoidable. Starting in 2008, the agency began refusing to pay hospitals for the cost of treating patients who suffered avoidable complications. For some time now, Medicare has been taking a hard look at readmissions, fining 2,610 hospitals this year alone for high rates.

Industry observers and healthcare system administrators question how Medicare makes its assessments. That’s because the methodology does not always distinguish clearly between the inherent infection risks with certain types of surgery and other infection types. Medicare groups them together in one HAI category. In addition, as hospitals proactively conduct HAI reduction programs, more infections are reported.

“How hard you look for something influences your results,” said Dr. Darrell Campbell Jr., chief medical officer at the University of Michigan Health System. “We have a huge infection control group, one of the largest in the country. I tell them to go out and find it.”

Each year, Medicare will be adding new injuries to its assessment list.

Surgical site infections are being added next October. In 2016, Medicare will look at rates for two antibiotic-resistant germs: Clostridium difficile, known as C. diff, and methicillin-resistant Staphylococcus aureus, or MRSA.

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HEALTHCARE ENVIRONMENTAL SOLUTIONS news 11

News Briefs

Super-Spreaders and the 80/20 Rule

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heffield, England – Writing on Conversation.com, Andrew Lee, senior clinical lecturer at the University of Sheffield in England, says most infections are spread by people who show no symptoms – “super-spreaders.”

One in five ‘super-spreaders’ responsible for the majority of viral infections

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hen it comes to the spread of infectious diseases, not all infected persons are equal. Some individuals seem to have a greater ability to spread infections than others. Indeed it is believed that around 80% of infections are thought to have been spread by 20% of infected individuals – a phenomenon also known as the 80/20 rule.

This phenomenon occurs not only in human populations, but also in animal populations, and involves both viral and bacterial infections.

A notable recent example was the Severe Acute Respiratory Syndrome (SARS) pandemic in 2003 where up to 75% of infections from Hong Kong and Singapore were linked to super-spreaders. Other infectious diseases where this phenomenon has been observed worldwide include outbreaks of tuberculosis, measles, cholera, as well as Ebola viral hemorrhagic fever.

What makes a super-spreader?

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hy such individuals become super-spreaders is less clear. Reasons that have been put forward include immune system deficiencies in these individuals and possibly a greater virulence of the pathogen. Co-infection with another pathogen can also push the spread of disease, as has been observed with HIV and other sexually-transmitted infections.

Overcrowding and group settings such as nurseries, schools, prisons and barracks, are also known to facilitate the spread of diseases such as

norovirus, Hepatitis A and influenza. In healthcare settings, delays in diagnosing infected persons and higher frequency of staff and patient transfers between wards and hospitals are other recognized risk factors.

Resistance versus tolerance

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he answer may lie in how the super-spreading individual’s immune system handles infection. One “resistance” mechanism involves the body’s immune system fighting off infection to control, if not eliminate, the pathogen. In the ensuing battle between host and pathogen, organ and tissue damage often occurs and these individuals often show symptoms.

The other way the body deals with infection is to “tolerate” the infection and limit the damage it causes. In doing so, this allows the pathogen to survive and thrive in the affected individual with no or minimal ill effects to either the host or the pathogen.

New research suggests that this “immune tolerant” second group may explain how some individuals become super-spreaders. The researchers were able to create mice with a super-spreader condition using antibiotics that eliminated much of their gut flora – this allowed a population of antibiotic-resistant pathogenic bacteria to flourish in the gut.

However, while these artificially created super-spreader mice were able to shed considerable numbers of the pathogenic bacteria as a consequence of antibiotic therapy, they also experienced considerable ill health. By comparison, mice that were natural super-spreaders suffered no apparent ill health from the use of antibiotics that disrupted their gut flora.

Unlike the artificially created super-spreader mice, these natural superspreaders were found to have a dampened immune response that probably explains their lack of ill health. They also found that by suppressing the immune system response of the non-super-spreader mice, this alleviated their symptoms of ill health.

Continued on next page

Product/Equipment Profiles Surfacide® UV-C Disinfection System Contributes to 39% Reduction in C.diff Infection Rates at NY Hospital

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a x t o n S t . L u k e ’s Healthcare (FSLH) in Utica, New York, recently presented data of its one year study on the effectiveness of its new Surfacide Helios Tr i p l e E m i t t e r U V- C disinfection system. Heather Bernard Director of Infection Prevention at Mohawk Valley Health System, presented data on January 8, 2015 summarizing a dramatic reduction of C.diff infections in 2014 at FSLH following the year-long use of bundled evidencebased interventions and Surfacide’s UV-C delivery technology.

The system utilizes ultra-violet (UV-C) light energy, an evidenced-based disinfection modality for controlling microorganisms, including those that are multi-drug resistant.

The Surfacide Helios system incorporates three separate emitters; allowing a larger area to be treated during a disinfection cycle and substantially reducing the problem of shadowed areas. Furthermore, the system includes a validation component using a proprietary laser mapping technology. This results in a more intense level of energy being delivered to every surface, in less time and with confirmation.

For more information, visit www.surfacide.com.

12 HEALTHCARE ENVIRONMENTAL SOLUTIONS news

jan-mar 2015

Recycling Cart Line Features Ergonomic, Hinged Panel

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e e s e Orbitron Dunne r e c y c l i n g collection carts and trucks now include the company’s novel, ergonomic, hinged side panel as an option. Designed to reduce bending and reaching inside the cart, and to eliminate the need for workers to lift heavy items over the rim.

Available on more than a dozen different recycle carts and trucks in a wide range of sizes, the ergonomic, hinged panel spans nearly the entire length of the rolling, plastic bin and opens and closes with an easy-to-use barrel bolt system that stays closed during transport. The plastic carts and trucks are also available with an optional, lockable security cover to prevent access through the hinged panel and support compliance with HIPAA. The line of recycling carts and trucks features rugged, rotationally molded, waterproof, plastic bins with the company’s signature poly base set atop premium, industrial-strength casters for high performance and long-term durability.

For more information, contact Jack Smylie at 800-829-4535 or jsmylie@modroto.com or visit www.RecyclingCarts.com.

News Briefs Continued from previous page

A hidden threat

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o what are the implications of this research for public health? Perhaps what is most worrying is that super-spreaders, by virtue of their “immune tolerance”, may show little if any signs of ill health.

Such individuals are a hidden threat who would continue to live and move freely within their communities where they could unwittingly transmit infection on to others. They present a real challenge for infectious disease control as they would be less likely to seek medical attention and even if they were to do so it would be difficult to identify them.

Antibiotics – a risk to human health?

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nother issue related to this research is about the role of antibiotics.

Antibiotics are often seen as the solution to the present and growing threat of infectious diseases. However, they may be the root cause of the problem of super-spreaders. Some individuals may have the innate ability

to become super-spreaders, which only becomes apparent when they are infected with a pathogen. But the use of antibiotics could lead to the creation of their super-spreader state.

Antibiotic over-use, even with the best of therapeutic intent, both in human and animal populations, may therefore worsen this situation. This re-affirms the urgent need for judicious and controlled use of antibiotics.

Current infectious disease-control measures such as mass screening, contact tracing and isolation of infected individuals tends to be laborious and not always effective. This is partly due to the fact that there are limited public health options available and disease-control responses tend to be reactive. If super-spreaders can be identified early in an outbreak, this may allow for a more finessed and effective approach to disease control.

Put it this way: if the 20% of infected individuals who spread 80% of infections are identified early and managed appropriately, 80% of onward infections within the community could be avoided – a tantalizing prize for public health.

Ebola Outbreak a Wake-Up Call, Report Warns

Infections Increase Death Risk by 35 Percent for ICU Patients

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Prevention Efforts Reduce Costs by More Than $150,000 per Patient

ashington – A policy report concludes that United States’ management and containment of severe diseases is inadequate, according to a SafetyandHealthMagazine.com article.

Key findings include the following issues:

Gaps in preparedness for emerging threats.

T

he timeliness of obtaining laboratory results and disseminating disease and other critical information has been weakening as public health and safety resources are reduced. One medical expert cited in the report noted that the United States waited until the disease arrived in the country before officials took serious steps to protect health care workers.

Decreasing Vaccination Rates.

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ore than 2 million preschoolers, 35 percent of seniors and a majority of adults do not receive all vaccinations recommended by the Centers for Disease Control. Only 14 states vaccinated at least half of their population against the seasonal flu (from fall 2013 to spring 2014).

Nearly one-quarter of health care workers were not vaccinated against the flu in 2013 and 2014. Only 35 states and Washington, D.C. met the goal for vaccinating young children against the hepatitis B virus (Healthy People 2020 target is 90 percent of children ages 19 to 35 months receiving at least 3 doses).

Healthcare-Associated Infection Rates.

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hile healthcare-associated infections have declined in recent years due to stronger prevention policies, around one out of every 25 people who are hospitalized each year still contracts a healthcare-associated infection. Only 16 states performed better than the national standardized infection ratio for central-line-associated bloodstream infections. Only 10 states reduced the number of central line-associated bloodstream infections between 2011 and 2012.

Sexually Transmitted Infections (STI) and Related Disease Treatment and Prevention.

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he number of new HIV infections grew by 22 percent among young gay men, and 48 percent among young Black men (between 2008 and 2010); more than one-third of gonorrhea cases are now antibiotic-resistant; and nearly three million Baby Boomers are infected with hepatitis C, the majority of whom do not know they have it. 37 states and Washington, D.C. require reporting of all (detectable and undetectable) CD4 and HIV viral load data, which are key strategies for classifying stage of disease, monitoring quality of care and preventing further transmission of HIV.

Food Safety.

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round 48 million Americans suffer from a foodborne illness each year.

Thirty-eight states met the national performance target of testing 90 percent of reported E.coli cases within four days (in 2011).

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EW YORK, NY – Elderly patients admitted to intensive care units (ICUs) are about 35 percent more likely to die within five years of leaving the hospital if they develop an infection during their stay, a new study finds. Preventing two of the most common health care-associated infections—bloodstream infections caused by central lines and pneumonia caused by ventilators—can increase the odds that these patients survive and reduce the cost of their care by more than $150,000, according to a study published in the January 2015 issue of the American Journal of Infection Control.

“Any death from preventable infections is one too many,” says senior study author Patricia Stone, PhD, RN, FAAN, director of the Center for Health Policy at Columbia University School of Nursing. “We’ve known for decades what works to prevent infections and save lives. Now, our study shows just how much money can be saved by investing in prevention.”

The study looked at outcomes for 17,537 elderly Medicare patients admitted to 31 hospitals in 2002, to assess the cost and effectiveness of infection prevention efforts. The researchers then used an additional five years of Medicare claims data to assess the long-term outcomes and health costs attributed to health care-associated infections.

While 57 percent of the elderly ICU patients died within five years, the researchers found that infections made death more likely. For those who developed central line-associated bloodstream infections (CLABSI), 75 percent died within five years, as did 77 percent of those who developed ventilator-associated pneumonia (VAP).

Effective prevention programs for CLABSI resulted in an estimated gain of 15.55 years of life on average for all patients treated in the ICU, the study found. Central line catheters deliver life-saving medicines and nutrition. Without proper insertion, utilization, and maintenance, catheters can also transmit deadly infections to the bloodstream. Simple infection prevention measures include hand washing before handling the catheter and immediately changing the dressing around the central line if it gets wet or dirty.

Efforts to prevent VAP resulted in an estimated gain of 10.84 years of life on average for all patients treated in the ICU. Ventilators, machines that force air into the lungs when patients can’t breathe on their own, can cause infections when patients lie flat in bed for long periods of time. Keeping patients elevated in bed, with the head higher than the feet, is one simple precaution that can help prevent pneumonia.

On average, the annual cost of running an infection prevention program in the ICU is about $145,000, the study found. Prevention efforts reduced ICU costs by $174,713 per patient for each instance of CLABSI, and by $163,090 for VAP. “This evidence points definitively to the value of investing in infection prevention,” says lead study author Andrew Dick, PhD, senior economist at RAND Corporation. jan-mar 2015

HEALTHCARE ENVIRONMENTAL SOLUTIONS news 13

News Briefs

CDC Designates 55 Ebola Treatment Centers • • • • • • • • • •

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

•

• • • • • • •

CDC HAI Reports for 2011 and 2013 Released

As of February 18, 2015 the treatment centers are: Maricopa Integrated Health Systems; Phoenix, AZ University of Arizona Health Network; Tucson, AZ Kaiser Los Angeles Medical Center; Los Angeles, CA Kaiser Oakland Medical Center; Oakland, CA Kaiser South Sacramento Medical Center; Sacramento, CA University of California Davis Medical Center; Sacramento, CA University of California Irvine Medical Center; Orange, CA University of California Los Angeles Medical Center; Los Angeles, CA University of California San Diego Medical Center; San Diego, CA University of California San Francisco Medical Center; San Francisco, CA Children’s Hospital Colorado; Aurora, CO Denver Health Medical Center; Denver, CO Emory University Hospital; Atlanta, GA Grady Memorial Hospital; Atlanta, GA Ann & Robert H. Lurie Children’s Hospital of Chicago; Chicago, IL Northwestern Memorial Hospital; Chicago, IL Rush University Medical Center; Chicago, IL University of Chicago Medical Center; Chicago, IL Johns Hopkins Hospital; Baltimore, MD University of Maryland Medical Center; Baltimore, MD National Institutes of Health Clinical Center; Bethesda, MD Baystate Medical Center; Springfield, MA Boston Children’s Hospital; Boston, MA Massachusetts General Hospital; Boston, MA UMass Memorial Medical Center; Worcester, MA Allina Health’s Unity Hospital; Fridley, MN Children’s Hospitals & Clinics of Minnesota; St. Paul, MN Mayo Clinic Hospital - Rochester, St. Marys Campus; Rochester, MN University of Minnesota Medical Center, West Bank campus, Minneapolis, MN Nebraska Medicine - Nebraska Medical Center; Omaha, NE North Shore System LIJ/Glen Cove Hospital; Glen Cove, NY Montefiore Health System; New York City, NY New York-Presbyterian/Allen Hospital; New York City, NY NYC Health and Hospitals Corporation/ HHC Bellevue Hospital Center; New York City, NY Robert Wood Johnson University Hospital; New Brunswick, NJ The Mount Sinai Hospital; New York City, NY MetroHealth Medical Center; Cleveland, OH Children’s Hospital of Philadelphia; Philadelphia, PA Hospital of the University of Pennsylvania; Philadelphia, PA Lehigh Valley Health Network - Muhlenberg Campus; Muhlenberg, PA Penn State Milton S. Hershey Medical Center; Hershey, PA University of Texas Medical Branch at Galveston; Galveston, TX Texas Children’s Hospital; Houston, TX University of Virginia Medical Center; Charlottesville, VA Virginia Commonwealth University Medical Center; Richmond, VA Children’s Hospital of Wisconsin, Milwaukee; Milwaukee, WI Froedtert and the Medical College of Wisconsin – Froedtert Hospital, Milwaukee; Milwaukee, WI UW Health – University of Wisconsin Hospital, Madison, and the American Family Children’s Hospital, Madison; Madison, WI MedStar Washington Hospital Center; Washington, D.C. Children’s National Medical Center; Washington, D.C. George Washington University Hospital; Washington, D.C. Harborview Medical Center; Seattle, WA Seattle Children’s Hospital; Seattle, WA Providence Sacred Heart Medical Center; Spokane, WA West Virginia University Hospital; Morgantown, WV

14 HEALTHCARE ENVIRONMENTAL SOLUTIONS news

jan-mar 2015

B • •

ethesda, MD – The Centers for Disease Control has released two reports that provide information on the status of hospital acquired infection rates and types.

Emerging Infections Program Healthcare-Associated Infection and Antibiotic Use Prevalence Survey The Healthcare-associated Infections (HAI) Progress Report.

HAI Prevalence Survey

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he CDC healthcare-associated infection (HAI) prevalence survey provides an updated national estimate of the overall problem of HAIs in U.S. hospitals. Based on a large sample of U.S. acute care hospitals, the survey found that on any given day, about one in 25 hospital patients has at least one healthcare-associated infection.

There were an estimated 722,000 HAIs in U.S acute care hospitals in 2011.

About 75,000 hospital patients with HAIs died during their hospitalizations.

More than half of all HAIs occurred outside of the intensive care unit.

Estimates of Healthcare-Associated Infections Occurring in Acute Care Hospitals in the United States, 2011

Major Site of Infection

Estimated No.

Pneumonia 157,500 Gastrointestinal Illness

123,100

Urinary Tract Infections

93,300

Primary Bloodstream Infections

71,900

Surgical site infections from any inpatient surgery 157,500

HAI Progress Report 2013

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he CDC National and State Healthcare-Associated Infections Progress Report is a report that gives a closer look at the healthcare-associated infections (HAIs) most commonly reported to CDC using the National Healthcare Safety Network (NHSN).

This is an annual report that describes national and state progress in preventing central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), select surgical site infections (SSI), hospital-onset Clostridium difficile infections (C. difficile), and hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections).

The current report is based on 2013 data. On the national level, the report found: • A 46 percent decrease in CLABSI between 2008 and 2013 •

A 19 percent decrease in SSIs related to the 10 select procedures tracked in the report between 2008 and 2013

•

A 6 percent increase in CAUTI between 2009 and 2013; although initial data from 2014 seem to indicate that these infections have started to decrease

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An 8 percent decrease in hospital-onset MRSA bacteremia between 2011 and 2013

•

A 10 percent decrease in hospital-onset C. difficile infections between 2011 and 2013

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Emergency Preparedness: Reconsidering On-site Disposal Options PAGE 1 Ebola Virus Remains Transmittable for Seven Days Post Mortem PAGE 6 RedAway Receives Approval for Texas Waste Facility PAGE 8 Medicare HAC Crackdown Results in $373 million in Penalties PAGE 10 Super-Spreaders and the 80/20 Rule PAGE 12 CDC Designates 55 Ebola Treatment Centers PAGE 14

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