COVID-19: An Ongoing Challenge for Both Healthcare Professionals and Infectious Waste Management

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by Kathleen Marquardt

COVID-19 is a coronavirus, one of a number of viruses that cause illnesses ranging from the common cold to highly fatal respiratory syndromes like SARS and MERS. COVID-19 is a new strain of coronavirus causing pneumonia-like symptoms. Researchers have now confirmed that the virus can spread via human-to-human transmission, though the original source of the virus has not been identified. Unlike other coronaviruses, COVID-19 has a much larger global spread and has infected more individuals than SARS and MERS combined. 

Individuals who have recovered from COVID-19 infection may have developed some protective immunity, but this has not yet been confirmed. A Japanese patient was said to have been re-infected, but experts note that it could also be a flare-up of the original disease. This shows us that, while medical leaders and researchers across the world are studying every aspect of this disease, they do not have a great handle on what it will do, or what, if anything but time, the antidote might be. On top of that, we have been exposed to different flu strains throughout our lives, which help us build immunity, but no one has immunity to this new virus.

We know who are hit the worst – the elderly and compromised, not the young. We also know that it mutates. “A new but preliminary study published in the National Science Review, the journal of the Chinese Academy of Sciences, said the more virulent of these two strains struck first, which explains the rapid transmissibility of the disease and its unnaturally high mortality rate during the first weeks of the COVID-19 outbreak in China. This more virulent strain exists alongside its less harmful cousin. The study identified these two strains as type L (the more virulent) and type S (which was found to be the ancestral version). “The study found the more aggressive type of SARS-CoV-2 accounted for roughly 70% of analyzed strains. On the other hand, 30% had been linked to a less aggressive type.”

Virologist Stephen Griffin, from University of Leeds in the U.K., explained that when RNA viruses first cross the species barrier into humans, they “aren't particularly well adapted to their new host (us!)," thus they mutate in order to “become better able to replicate within, and spread from human to human." 

Other experts expect more variants to be discovered as infections spike around the world and viruses adapts to new environments and hosts. One sample “ . . .of an American patient who had recently traveled to Wuhan suggested he might have been infected with both. Scientists say the possibility of a third mutation cannot be ruled out.” 

Yang Zhanqiu, a Wuhan-based virologist, told the Global Times recently that the American patient was probably infected with a third variant yet to be identified with enough samples. Usually a person can only be infected with one subtype of the coronavirus because different types clash with each other.

According to an article in the Journal of Medical Virology,  “some COVID‐19 patients also showed neurologic signs such as headache, nausea and vomiting. Increasing evidence shows that coronaviruses are not always confined to the respiratory tract and that they may also invade the central nervous system inducing neurological diseases. The infection of SARS‐CoV has been reported in the brains from both patients and experimental animals, where the brainstem was heavily infected.” Furthermore, some coronaviruses have demonstrated the ability to spread via a synapse‐connected route to the medullary cardiorespiratory center from the mechano‐ and chemoreceptors in the lung and lower respiratory airways. In light of the high similarity between SARS‐CoV and SARS‐CoV2, it is quite likely that the potential invasion of SARS‐CoV2 is partially responsible for the acute respiratory failure of COVID‐19 patients. Awareness of this will have important guiding significance for the prevention and treatment of the SARS‐CoV‐2‐induced respiratory failure. 

This makes it a whole new ballgame; there may be long-term affects through neurological diseases. All the more reason to avoid contracting it.

It is spread by droplets – people sneezing and coughing – so stay 6+ feet away from others. People who have the virus shed it everywhere they go.  It is on door handles, stair rails, light switches, car door handles, anything in public transportation that people grab onto – in other words, almost everywhere. 

What’s a person to do to protect oneself? According to the major sources – WHO, CDC, Mayo Clinic, and others, it’s simple. 

• Wash your hands;

• Don’t touch your face;

• Don’t touch door handles, knobs without gloves;

• Cover your mouth and nose with your bent elbow or tissue when you cough or sneeze;

• Put the toilet lid down before you flush. (How many toilet lids are found in hospitals, stores, restaurants, etc?)

And, of course, if you are concerned or need to be extra cautious, you should wear an N95 respirator mask, non-sterile disposable patient examination gloves for handles, rails, shopping carts, and anything else you must touch.

In the meantime, hospitals and other healthcare facilities are attempting to prepare for the worst. Massachusetts General Hospital in Boston went on television to show their warehouse of supplies, which is enormous, but the spokesperson admitted that it held only two weeks’ worth under the worst situation.

U.S. Health and Human Services Secretary Alex Azar testified before the Senate that the Strategic National Stockpile has just 30 million surgical masks and 12 million respirators in reserves, which came as a surprise considering that the stockpile’s inventory is generally not disclosed for national security reasons. Asked by National Geographic about the discrepancy, a senior official with the Strategic National Stockpile said the department intends to purchase as many as 500 million respirators and face masks over the next 18 months. The U.S. has not even 1/5th of what they project to need. Yet the CDC reports that we “might need as many as seven billion respirators in the long run to combat a worst-case spread of a severe respiratory outbreak such as COVID-19. 

And, according to Dr. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), that since the start of the COVID-19 outbreak, prices have surged. Surgical masks have gone up 600% in price, N95 respirators are up 300%, and surgical gowns have doubled in price. To meet rising global demand, WHO estimates that industry must increase manufacturing by 40 percent.

 Will these supplies be available? The supply chain may be greatly disrupted because many (if not most) of the products are made in China. And many of those not made in China have their parts produced elsewhere and put together in China or vice versa. Then there is the pharmaceutical aspect. According to the Council on Foreign Relations the U.S. imports an estimated 80% of the active ingredients used to make medication from China.

The CDC has studied contingency strategies if there is a shortage of N95 respirators nationwide. The strategies range from using respirators that have gone beyond the manufacturer-designated shelf life, those from other countries that are similar to NIOSH-approved N95 respirators, and even the re-use of N95 masks in certain situations. 

The impact of all of this on our healthcare providers, our doctors, nurses, and employees could be catastrophic. WHO says shortages are already leaving doctors, nurses and other frontline workers abroad dangerously ill-equipped to care for COVID-19 patients, due to limited access to supplies such as gloves, medical masks, respirators, goggles, face shields, gowns, and aprons. The U.S. may be better equipped than many countries, but the Mass General situation (one of the best) shows that we need to step up stockpiling, if we hope to provide our healthcare providers with adequate equipment and supplies as this virus progresses.

Because of the strong possibility that supplies will run short quickly if COVID-19 spreads faster as it is transported around the world, and because it has encircled the globe, it has already been classified as a pandemic. Vanderbilt University infectious disease specialist who’s been through the Asian, Hong Kong and Swine Flu epidemics says, “A pandemic is inevitable, and we should call it what it is. What’s not inevitable is that it will be severe.”

Whatever it is called, right now our country and the world have a two-pronged challenge: to tend to those infected and to protect our healthcare providers while they do the tending; that is if they are healthy and can do the tending. 

In California, because of potential exposure to an infected patient, . . .” the first documented instance of community transmission in the U.S. — left more than 200 hospital workers under quarantine and unable to work for weeks.” And because of possible contagion, many more there have been ordered to self-quarantine. In Washington, more than a quarter of a city’s fire department was quarantined after aiding several patients at a nursing home. 

If the number of new patients continues to rise and spread across the country, we could see a desperate need for healthcare works -- which don’t exist. With this situation, our hospitals and other medical facilities are now establishing new safety protocols.

Testing, itself, seems to be a major issue here. First, the CDC test kits that were dispensed across the U.S. to both state and local public health labs contain three reagents, one of which was defective and needed to be reformulated. Thus, replacement kits had to be reissued. The other issue with the tests kits is that, after the states get them, they must be able to replicate and validate their own performance in line with the CDC’s.

The testing kits being used for COVID-19 are presumptive tests, that is, tests that are used to determine whether a specific chemical (virus) is present in a solution. There must be a certain level of virus for the test to show positive. Those with a negative test but having all the symptoms may have to be tested numerous times. “The criteria for testing in the United States focuses on people who are ill with the spectrum of symptoms that we have associated with this, which is fever, respiratory symptoms, cough, shortness of breath who have had appropriate travel history or who have been identified as contacts of a confirmed patient.”

Right now, we have a major shortage of testing kits yet, at the same time the CDC says it is sending kits to over 30 other nations. 

Another issue about testing here came from the National Nurses Union. President Deborah Burger released a scathing statement from a quarantined nurse criticizing the CDC for its purported refusal to test her for coronavirus even though she had been exposed to the pathogen.

 “I know because I am currently sick in quarantine after caring for a patient who tested positive. I am awaiting permission from the federal government to allow for my testing even after my physician and county health professional ordered the test.” She added that “the CDC later contacted her to tell her that the delay in testing her was due to an “identifier number” and its decision to prioritize testing based on illness severity because of the limited amount of test kits.”

If the CDC wants to know how many cases there are and where, why are they delaying and denying tests, especially to one who would appear to be most likely infected? 

A key factor in a pandemic is the protection of the healthcare professionals that will be on the front lines. "We've not yet seen an epidemic or pandemic in our lifetimes of this size and scope," said Becca Bartles, the executive director of infectious disease prevention at Providence St. Joseph Health System. "We're gearing up for something extremely significant.” 

The American Hospital Association hosted a webinar in February, titled “What healthcare leaders need to know”. Dr. James Lawler, a professor at the University of Nebraska Medical Center showed a slide of ‘best guess’ estimates of:

• 4.8 million hospitalizations associated with the novel coronavirus.

• 96 million cases overall in the US.

• 480,000 deaths.

• Overall, hospitals should prepare for an impact to the system that is 10 times greater than a severe flu season.

A March 6 article in STAT, a biopharma, health policy, and life science analysis periodical, discusses how quickly COVID-19 could saturate and overwhelm the number of available hospital beds, facemasks, and other resources. But while inanimate things like masks and beds can be dealt with, we have a finite number of healthcare providers. If their numbers are reduced by infection from COVID-19, which is a given, our system could break down quickly.

In California, “health officials announced that two staff members at a Northern California hospital had contracted COVID-19 from a patient. A day earlier, officials said that a health worker at a Seattle nursing home had been hospitalized with the disease and that several more staff members would probably test positive in the coming days.”

This is in the very early days right now. 

Medical workers often have a higher rate of infection because of their close proximity and repeated exposure to a virus, thus more of them will be quarantined or admitted to the facility itself. Exhaustion and fatigue also take a toll, further reducing the number of those tending to the infected and hospitalized. There is not a warehouse of spare healthcare providers. On top of that, our colleges and universities are facing disarray and disruption as the students are instructed to no longer attend class and lectures but attend via computers. So, there may be a delay of new doctors, nurses, and tech workers. Thus, we need to take care of those we actually have.

We are facing too many unknowns that must be dealt with, and we need to be tending to them as soon as they emerge. The longer we wait, the graver the situation may become and the less able we will be to mitigate the problems.

And there is the question of handling the waste contaminated with COVID-19; the main problem is in volume if infected numbers rise rapidly. Unlike the situation with Ebola last year, COVID-19 is not classified as a Category A Infectious substance. Category A Infectious Substances present in a form that, when exposure occurs, are capable of causing permanent disability, life threatening or fatal disease in otherwise healthy humans or animals.

COVID-19 best practices call for “typical organization and administrative oversight, safe work practices and personal protective equipment such as puncture-resistant gloves, face shields, masks and eye protection.”

The U.S. had added waste treatment operations several years ago with the Ebola crisis. China has had to raise its medical waste handling capacity from 40-50 ton/day to 240 ton/day. They achieved it in 14 days. At a press conference Mr. Gong, of Gient Medical Waste Treatment Products in Ghongqing, stated, “The treatment capacity of Wuhan consists of the two original medical waste treatment plant with 50-60 ton/day, the newly build medical waste treatment plant 30 ton/day, some mobile treatment equipment. Also, the hazardous waste treatment plant and the waste to energy plant should help with the treatment of the waste. The whole treatment capacity reaches 264 ton/day, and 93.2% of the capacity is in operation, just enough. 

“China manages the waste in hierarchy. Different medical wastes were sent to different plants, for example: medical waste from the hospitals are sent to the medical waste treatment plants, medical waste plants take the most dangerous waste from the hospitals in Wuhan, like waste of quarantine hospitals, Leishenshan hospital and Huoshenshan hospital are sent to our newly built plant. The general waste from the quarantine points are sent to waste to energy plants but they are managed as medical waste.”

Here in the U.S. Arthur McCoy, of San-I-Pak, a company that produces on-site waste autoclaves told us that, “As the entire country witnessed just a few years ago, hospitals that lack the infrastructure to autoclave their infectious waste on-site can become vulnerable quickly as was the case at both Emory and Bellevue Hospital. Other hospitals that have on-site autoclaves, i.e., Nebraska Medical Center, quickly realized their limiting factor for how many patients they can treat was based on their autoclave capacity to process the infectious waste. All hospitals should strive to minimize infectious outputs (both infectious humans and infectious waste). On-site waste sterilizers are a best practice for reducing the spread of such deadly diseases.”  

COVID-19 is new and in many ways different from anything we have seen before. It may or may not taper off in warm weather. It may mutate again, even many times. It may or may not be a rerun of the Spanish flu. Whatever it is, we must treat it with all our resources until we are certain that it is contained.  

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