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Norovirus outbreaks continue to be a major seasonal problem and cause huge disruption to care services with substantial morbidity and mortality. What to do with Norovirus waste?
Much waste will be destined for the toilet or bedpan washer/macerator and though this creates a substantial risk of further aerosol distribution that is a matter for another day.
Inevitably, there will be large volumes of solid waste for disposal, much of it wet waste, and the ubiquitous plastic sack may be less than adequate. Double-bagging may reduce the risk of leakage but when large volumes of wet waste require disposal a rigid bin should be used as these have tight fitting lids that resist leaks and will not be compressed as they pass along the disposal route.
Some guidance exists. Compiled by HPA together with others, Guidelines for the management of norovirus outbreaks in acute and community health and social care settings offers much practical guidance on the management of Norovirus outbreaks. Sadly, waste management is largely ignored, presumably on the basis that once it leaves the ward the wastes are of no further concern. But that is not so; several cases of Norovirus infection have been recorded among waste handlers and it is likely that the true number is considerable. Regrettably, this latest document confuses healthcare waste and clinical waste and uses the two terms interchangeably. No further detail is provided.
- Great care is required in waste packaging, especially is leakage is likely to occur. Since waste sacks may be upended or compressed as they pass along the disposal chain and this is, in reality, almost inevitable.
- With much manual handling of wastes, exposure of ancillary and support staff and of waste handlers is almost inevitable. Exemplary hand hygiene and great care in glove use – especially important when gloves are not single-use disposal – is of great importance.
- Hand washing with hot water and soap is preferred, with alcohol hand-rubs being less reliable.
- The virus is able to survive on surfaces for considerable periods. One study reported 21-28 day survival in a dried state at room temperature; 2 studies reported virus survival for at least 12 days; 1 paper repeated sampling and did not find virus in a previously contaminated environment after 5 months. One further study suggested that carpets may have viable virus for at least 12 days that is not removed by routine vacuum cleaning. The survival of the virus on freshly removed waste sacks seems therefore inevitable and will create a potent source for exposure of the unwary.
- It is particularly important that waste managers, regulators and others should develop some basic understanding of care delivery and the practicality of Norovirus outbreak management. For example, the HPA guidance referenced above reminds us that patients may use newspapers and other reading materials during an outbreak and that these should be considered as contaminated waste and disposed accordingly. It is thus vitally important that those who might direct their enthusiasm toward ever better source segregation keep their noses, and their hands, out of waste sacks. During an outbreak, the volumes of outgoing wastes may increase dramatically with a substantial percentage of more innocuous items such as newspapers that must be managed as potentially hazardous waste.
- The high infectivity and ease of spread of Norovirus creates a particular risk for waste handlers. It is thus important to consider also the classification of Norovirus-related wastes that should be categorised as EWC 18 01 03 (wastes whose collection and disposal is subject to special requirements in order to prevent infection). That necessitates a yellow sack or bin, though the virus will be completely eradicated by all approved ATT processes and these wastes need not be incinerated.
- Waste sack holders should be decontaminated with 1,000 ppm chlorine
- Cart washers may present a particular problem. Carts may be soiled, often badly so with much contaminated free fluid in their base. Washers generally operate with minimal disinfection and a light detergent additive only. Almost all use water at room temperature only. Aerosol dispersal is not unlikely, and tests performed recently show some escape of air, water droplets and micro-organisms, though these tests did not include tests for Norovirus or any suitable virus marker. When Norovirus wastes are being handled, cart washing procedures should include supplementary virucide additives
Waste from Norovirus outbreaks requires particular care and exemplary hygiene standards. Waste handlers do develop infections after exposure to wastes. It is thus unacceptable that this important occupational hazard has been igorded by those formulating guidelines for the management of Norovirus outbreaks.