Monkeypox: CDC Updates Guidance for Medical Waste Handling

By A.J. Plunkett

The CDC has updated its guidance on infection control of monkeypox for healthcare settings, reminding providers that any case suspected of being of the more deadly Congo Basin clade requires more extensive precautions, including the handling of hazardous medical waste (HMW).

Be prepared to clean rooms of patients treated for monkeypox with healthcare workers (HCW) in appropriate personal protective equipment (PPE) and using disinfectants that are effective against monkeypox, recommends Marge McFarlane, PhD, MT(ASCP), CHFM, CHSP, CJCP, HEM, MEP, with Superior Performance Consultants in LaPointe, Wisconsin, and an expert on OSHA compliance.

She noted that according to U.S. Department of Transportation (DOT) hazardous materials information, an infectious substance is “classified as ‘Category A’ if it is in a form (i.e., untreated) capable of causing permanent disability or life-threatening or fatal disease in otherwise healthy humans or animals upon exposure to the substance.”

Any medical waste from a confirmed case of Congo Basin monkeypox or suspected as such must be treated under Category A, much like cases of Ebola or smallpox, according to the CDC’s guide to handling solid Category A waste, updated in June 2022.

Any waste from cases determined to be of the West Africa clade may be handled as Category B of regulated HMW. Category B is “an infectious substance that is not in a form generally capable of causing permanent disability or life-threatening or fatal disease in otherwise healthy humans or animals when exposure to it occurs.”

Category B also includes such waste as soiled dressings and contaminated sharps.

So far, most of the cases have been of the West Africa clade, according to the World Health Organization (WHO).

“During the ongoing 2022 multi-national outbreak of West African clade monkeypox, if a clinician or their public health authority determine that a patient does not have known epidemiological risk for the Congo Basin clade of monkeypox virus (e.g. history of travel to the Democratic Republic of the Congo, the Republic of Congo, the Central African Republic, Cameroon, or Gabon in the prior 21 days) it is appropriate to manage the patient’s waste as Regulated Medical Waste,” or Category A, said the updated CDC guidance. “However, if epidemiological risk factors indicate a risk for Congo Basin clade monkeypox virus, waste should be managed as a Category A infectious substance pending clade confirmation, and while local and state public health authorities are consulted.”

“Clinics and primary providers need to have a high index of suspicion and get patients tested for monkeypox,” and rooms cleaned and disinfected accordingly, says McFarlane.

Providers “may not be prepared with the correct disinfection protocols and consistent use of PPE,” she warned.

She says standard cleaning and disinfection procedures should be performed using an EPA-registered hospital-grade disinfectant with an emerging viral pathogen claim. The EPA released an updated list in late May.

Be sure personnel follow the manufacturer’s directions for concentration, contact time, and care and handling, says McFarlane.

She recommends focusing efforts on ensuring all suspicious and confirmed cases of monkeypox and handled with all the necessary PPE “every time. The CDC guidance states HCW need to wear face shields and N95 masks.”

Ensure that personnel are also trained and fit tested for their masks.

“I am more concerned about fit testing, availability of N95 masks and mask fatigue in staff. This would include training and education of staff turning over rooms in clinics. Linens can carry the monkeypox virus if [they] touched lesions. Linens need to be gathered with minimum agitation in full PPE and not held against the person.  Gowns and gloves need to be changed and hand hygiene performed consistently,” said McFarlane.

While it maybe tempting to treat all suspected or confirmed cases of monkeypox as Category A waste, McFarlane notes that the regulations for handling and transporting Category A waste are much more complicated and expensive.

Category A requires the use of special containers, which are expensive, and obtaining special handling permits, said McFarlane.

In addition, “not all medical waste vendors are able to take Category A waste. I think this is going to be the biggest challenge to determine if it is a Category A waste or not,” she said.

She recommended following the CDC guidance and document any potential Congo Basin travel, as outlined in the guidance, to determine if it needs to be treated as Category A waste. Update protocols and algorithms as needed, she said.

Remember to also educate laboratories on the risks, she said.

“This is where universal/standard precautions apply. The risk is the outside contamination of the blood vials, not the blood itself,” she said.

“Best practices would be wearing gloves when handling any specimen, gowns and face shields as required for potential BBP [bloodborne pathogen] exposure, handwashing and diligent counter disinfection,” adding a warning that “the virus is in lesion material that could have been transferred from the gloves of the phlebotomist to the outside of the blood vials.”

For more on patient care, management of healthcare personnel and patients with a monkeypox exposure, and visitation, as well as waste handling, see the CDC’s updated guidance:

Other resources can be found in the CDC guide on Category A waste handling, which is also recommended by the Department of Transportation, and can be found here.