The Crisis of Ebola

and Ebola-Contaminated Waste

in West Africa
PHILIPPINE COLLEGE OF PHYSICIANS (SL) MEETING
ALABANG, PHILIPPINES
27 JANUARY 2015

DR. JORGE EMMANUEL

CHIEF TECHNICAL ADVISOR
UNITED NATIONS DEVELOPMENT PROGRAM
EBOLA WASTE PROJECT
PRESENTED IN COOPERATION WITH
HEALTH CARE WITHOUT HARM

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)
Ta 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

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 (20-25C) / total darkness

1.5 days
90% reduction

99.99% reduction

Dried on plastic, metal, glass / room temperature

?

5.9 days

No survivors
when tested at
14 days

Note: Ebola was completely

inactivated sometime
before 14 days but
researchers did not
determine when.

Dried on solid surfaces, culture or sera / cold T (4C)

46 days
99% to 99.9% reduction

Note: Ebola survived

longer in the cold.

Environmental Persistence

Laboratory studies:

In artificial aerosols / 50-55% humidity / room T (22C)

15 minutes
50% reduction

Note: Aerosol droplets

fall to the ground and do
not remain suspended in
air.

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

Note: Cleaning & disinfection in the patient care environment increases protection.

Outside environment (direct solar radiation at noon)

1.5 hours
90% reduction

Estimate based on solar. UV radiation at noon

in West Africa from November 1-16, 2014

Persistence and Inactivation

Heat:
Ebola

is relatively fragile

Ebola

is reduced by 99.999% at 60C in 22

minutes
Heating

to 60C 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

Highlights of the Ebola Crisis

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

Highlights of the Ebola Crisis

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

Highlights of the Ebola Crisis

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

Highlights of the Ebola Crisis

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

Highlights of the Ebola Crisis

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 Ebolaaffected 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.

Ebola Emergency Response

Provision of PPE and disinfectants
Universal Precautions for Infection Prevention

Ebola Emergency Response

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

Crisis of Ebola-Infected Waste

Improper storage of infected waste

Crisis of Ebola-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 98C

PPE has flash ignition point of 343C
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

Waste Treatment and Dioxins

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 nonincineration 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)

Waste Treatment and Dioxins

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

Waste Treatment and Dioxins

Classified as a known human carcinogen by

IARC in 1997

Cancers linked to dioxins:

Chronic

lymphocytic leukemia (CLL)

Soft-tissue sarcoma
Non-Hodgkins lymphoma
Respiratory cancer (of lung and
bronchus, larynx, and trachea)
Prostate cancer

Waste Treatment and Dioxins

Developmental Effects

Birth defects
Alteration in reproductive systems
Impact on childs 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

Waste Treatment and Incineration

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, 750754 (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

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

Higher levels of lead, cadmium, and

toluene in the blood, and higher levels
of tetrachlorophenols and arsenic in
urine
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

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)

P. Gustavsson, Am. J. Ind.

Medicine, 15, 129-137
(1989)

Waste Treatment and Incineration (MWI)

600

554

Canada

Germany
MWIs

400
200
0
0
1984

2002
200
MWIs

On-Site MWIs

United States

Portugal

50
40
30
20
10
0

40

1
1995

Ireland
150

150
100
50

0
1990s

2005

2004

Non-Incineration Waste Treatment

Treatment technologies
Autoclaves- various sizes
Autoclaves with shredders
Hybrid autoclaves
Continuous steam treatment systems
Batch microwave units
Continuous microwave units
Frictional heating units

Crisis of Ebola-Infected Waste

My previous work

Waste Treatment
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

Personal Comments

Personal Comments

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