Letter Regarding the Oversight Hearing Examining the U.S. Public Health Response to the Ebola Outbreak
Dear Chairman and Ranking Member:
The Healthcare Coalition for Emergency Preparedness (HCEP), an organization with the primary mission to raise awareness on healthcare facility operational sustainability during a crisis or emergency, is concerned about preparedness issues related to Ebola, which is a harbinger for our readiness to treat emerging exotic diseases only an airplane ride away from the United States of America.
Centers for Disease Control and Prevention (CDC) Chief Tom Frieden was just quoted as saying, “We have to rethink the way we address Ebola infection control.” We whole heartedly agree. Now is not the time to cast blame or finger point. We need to quickly implement policies, procedures, and technologies to protect the integrity of our medical system, health care workers, and the public, and to promote confidence in our health system and government agencies ability to protect the public.
We hope that Congress, along with the CDC, National Institutes of Health (NIH), Assistant Secretary for Preparedness and Response (ASPR), medical trade associations, such as the American Hospital Association (AHA), State and County Health Officials, and HCEP, can all work cooperatively toward implementing simple, effective solutions using readily available technologies to implement appropriate protocols, establish designated treatment centers, and utilize the best American and international guidelines regarding infection control procedures and preparedness in our hospitals.
We believe that there are simple solutions that can be implemented quickly, including designated treatment centers; utilize mobile triage centers; recommend more conservative protections for healthcare workers; establish protocols for patient movement; disinfect solid and liquid waste on-site as close to the source as possible; and consider deploying mobile waste sterilizers to medical centers.
The Nebraska Medical Center that treated an American doctor infected with Ebola is a good example of safe and effective protocols and technology. However, we currently have only four U.S. hospitals with top-level bio-containment units, which have a very limited capacity to treat patients. Overall, our system would be stressed if dozens of patients or more were infected. We know that some hospitals are simply not prepared to treat such exotic infectious diseases. We should realize that most hospitals should not be used to treat Ebola and other such Category A infectious diseases; instead, we could look to centralized treatment centers with highly trained staff. Such an action would help maintain the integrity of our nation’s hospitals to continue to safely treat the American public while Ebola patients are treated and the disease is contained. Among the benefits of centralized treatment centers would be the isolation of patients away from others and for the efficient utilization of supplies, trained staff, and infection control at the site.
We urge States to work with local health officials and healthcare providers, in coordination with federal health resources, to ensure that those afflicted with Ebola (or other such Category A illnesses) are routed to designated hospitals or high-capacity facilities. These should be set up with trained staff to treat such patients and equipped to meet domestic and international standards for patient care, infection isolation, and on-site sterilization with proper handling protocols for such infectious substances. For a large outbreak, trying to treat many patients at many hospitals potentially exposes too many people and requires vast resources dispersed across many hospitals.
Additionally, with healthcare workers on the front lines in the battle to contain Ebola, the need for proper Personal Protective Equipment (PPEs) and infection control protocols is paramount. We know that there is not much information and research on disease transmission in the healthcare setting, including the potential for infectious particles to be suspended in the air around a symptomatic patient. Thus, it only seems appropriate to adopt more conservative measures to protect healthcare providers.
We are pleased to note that CDC has now clarified that Ebola waste is a Category A infectious material, which the Department of Transportation (DOT) determines is capable of posing an unreasonable risk to health, safety, and property when transported in commerce, and should not be treated like normal regulated medical waste (RMW). You can view attached the latest CDC update on Ebola waste at http://www.cdc.gov/vhf/ebola/hcp/medical-waste-management.html.
As you know, Ebola waste is very contagious as it contains the infected body fluids that transmit the disease from one person to another. The deadly consequences of Ebola waste was, unfortunately, just reinforced by the recent death of an Ebola victim in Germany who was in charge of medicals waste disposal at a clinic in Liberia. Therefore, the matter of addressing Ebola waste is a misunderstood danger and public risk that must be responsibly and realistically addressed as part of a complete ‘creation to sterilization’ infection control process on-site where such patients are treated. In addition to performing on-site sterilization of Ebola waste before it is removed from the facility, liquid Ebola waste should be disinfected before it is put into a municipal sewer system. CDC notes that the virus can be effectively killed with autoclave sterilization and bleach solutions, stating, “Ebola-associated waste that has been appropriately inactivated or incinerated is no longer infectious.”
It is important to know that, as recent as 20-25 years ago, most hospitals had on-site technology (incineration) to quickly and effectively destroy any contagious waste, but that was discontinued as a result of EPA regulations to reduce toxic emissions. Today, just 20% of hospitals have on-site technology (autoclaves). Most institutions outsource the treatment of medical waste, trucking it through communities to a central processing center. Nearly all of the top ranked medical institutions (Hopkins, Stanford, Cleveland Clinic, Mayo, UCLA, and others) utilize on-site sterilization technology, which is readily available and affordable.
At Emory Medical Center, one of the Ebola patients was producing up to 40 bags of contagious waste a day. If there was an outbreak, it would be unlikely that any truck transporter would have the capability, i.e. Haz-Mat trucks, drivers, and DOT approved containers, etc., to safely manage this deadly material. This situation would further be complicated by insurance and regulatory challenges as hospitals are legally liable for the disinfection of any waste they produce. Thus the material should be secured and monitored by the waste producer until treated. Our coalition has found that when the transportation infrastructure is challenged, due to weather or other natural/man-made forces, hospitals can be crippled. On-site sterilization should be the final link in the infection control chain to quarantine and treat this deadly waste to stop this disease, and recommend that we consider options for all Level 1 trauma centers and government hospitals should have such capabilities. In addition, the CDC or States may wish to consider securing mobile sterilization units that can be stationed around the country and deployed as needed.
To recap, the HCEP urges Congress, public officials and healthcare providers and associations to work together to protect healthcare workers and the public, and to consider the following recommendations:
- Develop designated or centralized treatment centers with highly trained staff
- Deploy Army Mobile Triage Centers to keep suspected patients isolated
- Adopt more conservative measures to protect healthcare providers
- Establish protocols for the movement and transportation of patients, and subsequent disinfection
- Ensure sterilization of all Ebola/Category A waste on-site/as close to the source as possible
- Encourage Level 1 Trauma Centers and government hospitals to have on site waste treatment capability
- Disinfect liquid Ebola waste before it is put into a municipal sewer system
- Have CDC or states consider procurement and utilization of mobile waste sterilizers
In conclusion, we believe hospitals are working hard to be prepared to protect the American public. While many may suggest that we need to spend more, we would advise policy makers to take a more thoughtful comprehensive approach. Allocating our resources towards preparedness and response solutions for public health based on current and near ready technologies is a better solution.
We request that this letter be added to the hearing record. Further, we would be happy to discuss this letter and our recommendations in depth at your convenience. Please feel free to reference our web site (www.healthcareprep.org/Ebola), which is continually updated, and utilize our organization for additional information. Thank you for your consideration of our thoughts and suggestions.
Darrell A. Henry