Feb 4, 2020.
The World Health Organization (WHO) states the Wuhan 2019 new coronavirus (nCoV) has prompted an “overabundance of information” and trustworthy sources are essentialfor instituting evidence-based prevention measures as some information is not accurate.1 Trustworthy up-to-date sources relevant to U.S. (in addition to state and federal regulations) are WHO,1the U.S. Dept of Labour Occupational Safety and Health Administration(OSHA),2 andthe U.S. Centers for Disease Control and Prevention (CDC).3,4,5The following is extracted from these sources.
What is nCoV?
Coronaviruses are a family of seven virusescommon in many animals, including camels, cattle, cats, and bats.4Common human coronaviruses usually cause mild to moderate upper-respiratory tract illnesses, like the common cold. However, rarely, animal coronaviruses can infect people and then spread between people such as with Middle East Respiratory Syndrome (MERS), Severe acute respiratory syndrome (SARS), and now, Wuhan 2019-nCoVin Dec 2019.4
Symptoms of nCoVinfection may appear between 2 to 14 days after exposure and can include fever, cough and shortness of breath, however in some of cases the illness can be severe and fatal.3
World and U.S. situation
By Feb 4, 2020, 20,630 cases from 24 countries had been reported to WHO(20,471 cases (99.2%) in China).1aSevere illness occurred in 13% with 425 deaths (2.1%).1aThe mortality rate has remained constant however the number of cases in China rises daily. The U.S. has reported 11 confirmed cases.1aNo new countries reported nCoV in the last 72 hours.1,1a
OSHAand CDCstate the immediate health risk to the general American public is low.2,3However, airline, healthcare and border-protection workers may have exposure risk via travelers infected with the virus, and business travelers may be at risk while visiting areas abroad where the virus is spreading.2
Mode of Transmission
On current evidence, CDC statespread from person-to-person is most likely among close contacts (about 6 feet) mainly via respiratory droplets produced when an infected person coughs or sneezes.5,6These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.5The risk of transmission from touching a contaminated surface or object is currently unclear.5 Transmission via non-symptomatic people has been reported in one 4-case cluster,5but is now refuted.
How “Infectious” is nCoV?
Infectivity is calculated mathematically and termed “R0” (“R-naught”) which is the number of new cases likely to occur from each case. WHO state nCoV R0is likely between 1.4-2.5,7and the upper limit is similar to the R0 of 3 for SARS,8but less infectious than the upper limit of 1.0-5.7 for MERS.9By comparisoninfluenza is 1.3 (Seasonal) to 1.8 (Pandemic) and measles R0 is 12-18.10 At a current mortality rate of 2%,1nCoV is considerably less fatal than SARS (11%),8and MERS (35%).9
How can HCP protect themselves against nCoV?
Clear updated guidelines for healthcare professionals (HCP) protection are available at OSHA2and CDC6and CDC advises that administrative rules and engineering controls, environmental hygiene, correct work practices, and appropriate use of personal protective equipment (PPE) are all necessary to prevent infections, and All HCP who enter the room of a patient with suspected or confirmed 2019-nCoV should adhere to Standard, Contact, and Airborne Precautions, which along with hand hygiene may include gloves, gowns, respiratory and eye protection.6
How is nCoV waste handled?
Waste from nCoV patients is handled as standard regulated medical waste (RMW).6,11
In their nCoV Infection Prevention Recommendations, CDC state, “Management of …. medical waste should also be performed in accordance with routine procedures”,6and refers readers to the RMW chapter of their 2003 Environmental Infection Control Guidelines.11
For nCoV waste containment onsite, the RMW Guidelines state:
- A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag’s exterior.
- Contamination or puncturing of the bag requires placement into a second biohazard bag.
- All bags should be securely closed for disposal.
For transport of nCoV waste offsite the US Dept of Transport RMW 49 CFR 49 173.134(c)requires the above RMW plastic bags be contained in a rigid container,12and 49 CFR 172.10113 requires it be transported as “UN 3291Regulated medical waste, n.o.s. or Clinical waste, unspecified, n.o.s. or (BIO) Medical waste, n.o.s., or Biomedical waste, n.o.s. or Medical waste, n.o.s.”(i.e. standard RMW transport packaging).
Note. Specimens from suspect nCoV cases and cultures of nCoVare Category B substances and must be packaged and transported as UN 3373 when sent offsite.14
How is nCoV waste treated?
As nCoV waste is standard regulated medical waste, theRMW chapter of the CDC 2003 Environmental Infection Control Guidelines11states:
- Regulated medical wastes are treated or decontaminated to reduce the microbial load in or on the waste and to render the by-products safe for further handling and disposal.
- The treatment need not render the waste “sterile”
- Treatment processes are licensed under each state’s medical waste regulations and treatment methods may include autoclaving, incineration, chemical disinfection, grinding/shredding/disinfection methods, energy-based technologies (e.g., microwave or radiowave treatments), and disinfection/encapsulation method
Can reusable sharps containers be used for nCoV wastes?
Yes. nCoV is classified as RMW and reusable sharps bins may be used provided the sharps container:
- Meets OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030requirements.15
- Meets FDA requirements for pre-market clearance.16
- Meets USDOT 49 CFR 173.134(c)2(x)requirements,17is transported in accord with 49 CFR 172.10113and meets the USDOT additional requirements for reusable sharps containers stipulated in 49 CFR 173.197(e)(3),18being:
(ii) The sharps container must be permanently marked for reuse.
(iii) The sharps container must be disinfected prior to reuse by any means effective for the infectious substance the container previously contained.
(iv) The sharps container must have a capacity greater than 7.57 L (2 gallons) and not greater than 151.42 L (40 gallons) in volume.
- Outer surface is decontaminated before it leaves the patient room as per Jan 28, 2020 CDC nCoV Infection Prevention recommendations.6
Note 1. WHO statespreliminary information suggests the virus may survive a few hours on surfaces and that simple disinfectants can kill the virus.20
Note 2. Decontamination of sharps bins is not “routine RMW practice” but is a safety precaution for handlers as it severs any possible transmission if aerosol deposition and viable nCoV were possible on reusable sharps containers.
Note 3. Under CDC nCoV Infection Prevention recommendations,staff and contractors entering patient rooms (to exchange reusable sharps containers) are required to wear PPE appropriate to the “6-feet” rule and facility protocols.6
Can reusable RMW bins be used for nCoV wastes?
Yes. nCoV is classified as RMW and reusable RMW bins may be used provided the bins:
- Meet US Dept of Transport 49 CFR 49 173.134(c)for rigid containers,12and are transported as Un 3291 in accord with 49 CFR 172.101.13
- Meet state RMW requirementsfor decontamination between uses.19
- Novel Coronavirus (2019-nCoV). Situation Reports – 131(Feb 2, 2020) and 141a(Feb 3, 2020) World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports.Accessed Feb 3, 2020.
- Occupational Safety and Health Administration2019 Novel Coronavirus. Feb 2, 2020. https://www.osha.gov/SLTC/novel_coronavirus/standards.html. Accessed Feb 3, 2020.
- Coronaviruses – Symptoms and Diagnosis. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/about/symptoms.html. Accessed Feb 3, 2020.
- 2019 Novel Coronavirus (2019-nCoV) Situation Summary. Feb 1, 2020. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-nCoV/summary.html. Accessed Feb 3, 2020.
- How 2019-nCoV Spreads. Jan 31, 2020. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Accessed Feb 2, 2020.
- Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (2019-nCoV) in a Healthcare Setting. Jan 28, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html. Accessed Feb 3, 2020.
- Statement on the meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). https://www.who.int/news-room/detail/23-01-2020-statement-on-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov). Accessed Feb 3, 2020.
- Consensus document on the epidemiology of severe acute respiratory syndrome (SARS). World Health Organization. https://www.who.int/csr/sars/en/WHOconsensus.pdf. Accessed Feb 3, 2020.
- WHO MERS-CoV Global Summary and Assessment of Risk, July 2019 (WHO/MERS/RA/19.1). Geneva, Switzerland: World Health Organization; 2019. https://apps.who.int/iris/bitstream/handle/10665/326126/WHO-MERS-RA-19.1-eng.pdf?ua=1. Accessed Feb 3, 2020.
- Biggerstaff M, Cauchemez S, Reed C, Gambhir M, Finelli L. Estimates of the reproduction number for seasonal, pandemic, and zoonotic influenza: a systematic review of the literature. Centers for Disease Control and Prevention. BMC Infect Dis. BMC Infectious Diseases 2014, 14:480. http://www.biomedcentral.com/1471-2334/14/480. Accessed Feb 3, 2020.
- Regulated Medical Waste, Chapter I, Part 1 of Guidelines for Environmental Infection Control in Health-Care Facilities (2003) Updated: July 2019. https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/medical-waste.html. Accessed Feb 3, 2020.
- 49 CFR 173.134(c) – Exceptions for regulated medical waste. US Department of Transportation. https://www.law.cornell.edu/cfr/text/49/173.197. Accessed Feb 3, 2020.
- 49 CFR 172.101 Hazardous Materials Table. US Department of Transportation. https://www.ecfr.gov/cgi-bin/text-idx?SID=ae15ede2730beed1bb677b2021049803&mc=true&node=se49.2.172_1101&rgn=div8. Accessed Feb 3, 2020.
- Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with 2019 Novel Coronavirus (2019-nCoV). Feb 2, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/lab/lab-biosafety-guidelines.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Flab-biosafety-guidelines.htmlAccessed Feb 3, 2020.
- 29 CFR 1910.1-30. OSHA Bloodborne Pathogens Standard. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS. Accessed Feb 3, 2020.
- Guidance on the content and format of premarket notification [510(k)] submissions for sharps containers. Infection Control Devices Branch, Office of Device Evaluation, US Food and drug Administration. https://www.fda.gov/media/72328/download. Accessed Feb 3, 2020.
- 49 CFR § 173.134 – Class 6, Division 6.2 – Definitions and exceptions. US Department of Transportation. https://www.law.cornell.edu/cfr/text/49/173.134. Accessed Feb 3, 2020.
- Regulated Medical Waste: Sharps. 49 CFR 173.197(e)(3). US Department of Transportation. US Department of Transportation. https://www.law.cornell.edu/cfr/text/49/173.197. Accessed Feb 3, 2020.
- State-by-State Regulated Medical Waste Resource Locator. Healthcare Environmental Resource Center (HERC). http://www.hercenter.org/rmw/rmwlocator.php. Accessed Feb 3, 2020.
- How long does the virus survive on surfaces? WHO Q&A on Coronaviruses. Feb 2, 2020. World Health Organization. https://www.who.int/news-room/q-a-detail/q-a-coronaviruses. Accessed Feb 3, 2020.