Sanitation interventions during Ebola epidemic

  • Sowmya
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Re: Sanitation interventions during Ebola epidemic

[Start of Page 3 of the discussion]


I think your point is very important. In Ebola containment, we need to think of toilets that may be in bad condition also (built too long ago or not constructed properly, etc.,) - cleaning / disinfecting would be all the more difficult in such cases. If it is not possible to use disinfectant chemicals (because the discharge might get mixed with the compost / fertilizer to be added to the fields), there could be a risk of infection.

Taking all these factors into consideration, it might be best to adopt the normal cleaning procedure for the toilet with the proviso that users wash their hands and feet thoroughly with soap and water outside the toilet (preferably with the water going into a small hole in the ground so that there is no unsightly pool of dirty water stagnating near the toilet) and, after drying, to dust their hands and feet with antiseptic / germicidal powder.

The small hole should probably be not more than 1-1.5 feet deep and 1-1.5 feet diameter as the hole should not be large enough to allow children or small animals to get hurt while running and preferably be kept closed with a lid that will not break into sharp shards if someone stamps on it accidentally - maybe a plastic / rubber ring (eg., a used pressure cooker gasket) with brightly-colored plastic cover on it. Or, can always use bamboo like the ones used for making baskets to make the ring. Probably better solutions are available but I am just thinking of the most resource scarce situation possible and without the possibility of quickly distributing required materials.

A germicidal solution, like Dettol or Savlon, could also be used instead of germicidal powder (I do not have scientific evidence but if other proven options are not available, this could probably be used). Further, for public toilets, a good solution could be the arrangements MSF had made for the hospital in Kitwit (please see article referred by Joe) to have a footbath. Individuals going from one area to the other had to wade through a tray filled with disinfectant (Pedi-Luve or foot bath). The material used had been developed, adapted and tested by MSF during previous emergency situations. 0.2% Calcium Hypochlorite solution 70% was used for the footbath. Something similar could also be used in households, if possible.

Warm regards,

Sowmya

Sowmya Rajasekaran
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  • arno
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Re: Sanitation interventions during Ebola epidemic

Joe
Here is a paper on Noroviruses transferred via faeces on environmental surfaces. Drawing parallels with Filoviruses isn't really a long shot. Protecting against the highly contagious and persistent Noroviruses should provide the proper safety to protect against Ebola.

www.sciencedirect.com/science/article/pii/S0195670104002087

Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces by J. Barker, I.B. Vipond, S.F. Bloomfield.
Journal of Hospital Infection. Volume 58, Issue 1, September 2004, Pages 42–49

Abstract
A reverse transcriptase polymerase chain reaction assay was used to study the transfer of Norovirus (NV) from contaminated faecal material via fingers and cloths to other hand-contact surfaces. The results showed that, where fingers come into contact with virus-contaminated material, NV is consistently transferred via the fingers to melamine surfaces and from there to other typical hand-contact surfaces, such as taps, door handles and telephone receivers. It was found that contaminated fingers could sequentially transfer virus to up to seven clean surfaces. The effectiveness of detergent– and disinfectant-based cleaning regimes typical of those that might be used to decontaminate faecally contaminated surfaces and reduce spread of NV was also compared. It was found that detergent-based cleaning with a cloth to produce a visibly clean surface consistently failed to eliminate NV contamination. Where there was faecal soiling, although a combined hypochlorite/detergent formulation at 5000 ppm of available chlorine produced a significant risk reduction, NV contamination could still be detected on up to 28% of surfaces. In order consistently to achieve good hygiene, it was necessary to wipe the surface clean using a cloth soaked in detergent before applying the combined hypochlorite/detergent. When detergent cleaning alone or combined hypochlorite/detergent treatment failed to eliminate NV contamination from the surface and the cleaning cloth was then used to wipe another surface, the virus was transferred to that surface and to the hands of the person handling the cloth. In contrast, were surfaces where contaminated with NV-infected faecal suspension diluted to 1 in 10 and 1 in 80, intended to simulate surfaces that have become contaminated after secondary transfer, treatment with a combined bleach/detergent formulation, without prior cleaning, was sufficient to decontaminate surfaces and prevent transfer.

Arno Rosemarin PhD
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  • joeturner
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Re: Sanitation interventions during Ebola epidemic

Thanks full paper here: www.processcleaningsolutions.com/pdf/3_norovirus-barker.pdf

The paper seems to make clear that wiping and the use of detergent is not enough to clean surfaces of the virus. The use of a bleach, preferably with surfaces wiped beforehand, seems to be the advice given in this paper to reduce risks.
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  • joeturner
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Re: Sanitation interventions during Ebola epidemic

I have found another paper which might give useful information:

Tuladhar, Era, et al. "Residual viral and bacterial contamination of surfaces after cleaning and disinfection." Applied and environmental microbiology 78.21 (2012): 7769-7775.

Full text: aem.asm.org/content/78/21/7769.full

Abstract:

Environmental surfaces contaminated with pathogens can be sources of indirect transmission, and cleaning and disinfection are common interventions focused on reducing contamination levels. We determined the efficacy of cleaning and disinfection procedures for reducing contamination by noroviruses, rotavirus, poliovirus, parechovirus, adenovirus, influenza virus, Staphylococcus aureus, and Salmonella enterica from artificially contaminated stainless steel surfaces. After a single wipe with water, liquid soap, or 250-ppm free chlorine solution, the numbers of infective viruses and bacteria were reduced by 1 log10 for poliovirus and close to 4 log10 for influenza virus. There was no significant difference in residual contamination levels after wiping with water, liquid soap, or 250-ppm chlorine solution. When a single wipe with liquid soap was followed by a second wipe using 250- or 1,000-ppm chlorine, an extra 1- to 3-log10 reduction was achieved, and except for rotavirus and norovirus genogroup I, no significant additional effect of 1,000 ppm compared to 250 ppm was found. A reduced correlation between reduction in PCR units (PCRU) and reduction in infectious particles suggests that at least part of the reduction achieved in the second step is due to inactivation instead of removal alone. We used data on infectious doses and transfer efficiencies to estimate a target level to which the residual contamination should be reduced and found that a single wipe with liquid soap followed by a wipe with 250-ppm free chlorine solution was sufficient to reduce the residual contamination to below the target level for most of the pathogens tested.

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  • arno
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Re: Sanitation interventions during Ebola epidemic

Ebola Outbreak: NEJM Live Audio Webcast.

click2.nejm.org/cts/click?q=66666779%3B6...BrvS9GG5aww20Dc%2Bfa

A special invitation for valued readers of the New England Journal of Medicine, a publication of NEJM Group.

NEJM Live Audio Webcast:
Ebola Outbreak
Experts discuss virology, epidemiology, and clinical care
October 22, 2014 | 2:00 pm - 3:30 pm ET

What Clinicians Need to Know
International experts with hands-on experience provide the latest information on the Ebola outbreak, including recent events in the U.S., protection for health care professionals and the general public, and projections for the future.

Learn more about this free live audio webcast hosted by the New England Journal of Medicine, including the full agenda and guest speakers. Webcast participants will also have an opportunity to submit questions live or in advance by sending their questions to This email address is being protected from spambots. You need JavaScript enabled to view it..

GUEST SPEAKERS & MODERATORS
Christopher Dye, D.Phil.
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Médecins Sans Frontières

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Editor-in-Chief The New England Journal of Medicine

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Follow the live event on Twitter: #NEJMEbola

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  • jonpar
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Re: Sanitation interventions during Ebola epidemic

many thanks Roslyn for sharing this and thanks for SuSanA members for your contributions... I have shared this with my colleagues here at Oxfam GB. best regards, Jonathan

Dr. Jonathan Parkinson
Principal Consultant – Water and Sanitation
IMC Worldwide Ltd, Redhill, United Kingdom
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  • Roslyn
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Re: Sanitation interventions during Ebola epidemic

Thank you everyone for the feedback and continued discussion on this pressing and important topic. I have recently come across a couple sources which highlight articles which are relevant to Ebola and WASH that I would like to further highlight:

1) WASHplus Weekly and WHO WASH and Ebola FAQ


Dan Campbell recently made a post on the forum about the WASHplus Weekly Issue 167, 31.10.14 which has a focus on WASH and Ebola. There are several noteworthy articles and documents in this list, with over 20 articles and documents directly related to the subject (ranging from overviews of Ebola and WASH to handwashing to anthropological studies).

In particular I would like to bring attention to the WHO document “Ebola Virus Disease (EVD): Key Questions and Answers Concerning Water, Sanitation and Hygiene” www.who.int/water_sanitation_health/WASH_and_Ebola/en/
It relates to several points which were discussed here, in particular in relation to the 5 questions that I had previously extracted from the conversations. The key topics which relate to sanitation in this WHO document include:
  • Infection, and survival of the virus in drinking water contaminated by faeces/ urine (p. 1)
  • Minimum WASH requirements (and separation of excreta and drinking water) (p. 1)
  • Recommended handwashing procedures (p. 1)
  • Recommended sanitation facilities (p. 2)
  • Treatment requirements of faeces and urine in health facilities (p. 2)
  • Emptying of latrines/ septic tanks and excreta transportation (p. 3)
  • Wastewater and greywater treatment (p. 3)
  • Surface, bedding, health care waste disposal considerations (p. 4)
  • Additional considerations in handling faeces and urine (p. 4)
  • Key references with links (p. 5)
Perhaps if someone is interested to further discuss this document and the recommendations provided, a separate thread could be made.


2) 2014 Water and Health Conference Ebola and WASH Session

The 2014 Water and Health Conference (13-17.10.14 in Chapel Hill, USA) held a special Ebola and WASH session. Here is the link to the session discussion: whconference.unc.edu/ebola-wash/ .

They also have a PDF available of the presentation from the panel. Here are some highlights from the document:
  • p. 12: discussion on transmission
  • p.19: discussion on “Survival of Ebola virus and other viruses in human wastes and in environmental media: what we do and do not know”(presented by Mark D. Sobsey, University of North Carolina)
  • p. 30: Ebola and WASH: Water, sanitation and hygiene measures to control the spread of Ebola virus from patients through environmental media to other people. What do we know? (presented by Huw Taylor, University of Brighton)
This discussion thread has now become quite long - for any particular topics which come out of this discussion and these articles, perhaps a new thread(s) could be started to further focus on particular aspects?

Thank you again for the input, links, and resources that have been provided in this thread!

Roslyn

Roslyn Graham
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  • campbelldb
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Re: Question re: latrine sludge temperatures and Ebola

I received the email below from a colleague re: sludge temperatures and Ebola. Please let me know if you have contacts or studies that would be useful and I will compile and share the responses.

Many thanks,
Dan Campbell

Do you know of any research on what temperature the sludge in a pit latrine in an African context gets to during normal use? If not do you know anybody who may. We are trying to estimate the survival of Ebola in pit latrines.

In not is there a group to which you could circulate the question?

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  • muench
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Re: Question re: latrine sludge temperatures and Ebola

Dear Dan (and the anonymous person asking the question),

As there is only limited amount of composting going on in a pit latrine (if any at all!), I would guess that the temperature in the pit latrine is the same as ambient temperature. As it in the soil and not in direct sunlight, I would guess it is usually between 20-25 deg C, depending on the climate (max day time temperatures, minimum night time temperatures).

In any case, the Ebola virus is likely to die off within a matter of days. I say this because I recently looked for information about survival of the Ebola virus in urine when I edited the Wikipedia page on UDDTs with respect to treatment of urine for reuse in agriculture (see en.wikipedia.org/wiki/Urine-diverting_dr...#Further_treatment_2 )

I wrote there:

The Ebola virus may also be found in urine from an infected person. The exact survival time of this virus in human urine outside of the human body is unclear but probably "up to several days" like with other body fluids at room temperature.[27]


Reference 27 is:
"Ebola (Ebola Virus Disease)Transmission, Q&As on Transmission". CDC (Centres for Disease Control and Prevention). 20 November 2014. Retrieved 5 January 2015.

www.cdc.gov/vhf/ebola/transmission/qas.html

Where it says:

How long does Ebola live outside the body?
Ebola is killed with hospital-grade disinfectants (such as household bleach). Ebola on dry surfaces, such as doorknobs and countertops, can survive for several hours; however, virus in body fluids (such as blood) can survive up to several days at room temperature.


So in summary, don't rely on any raised temperatures in the pit latrine, rely on the fact that the virus outside of the human body survives only for up to several days.

Kind regards,
Elisabeth

P.S. Also useful might be the summary post about Ebola and sanitation that Roslyn did here on 5 November 2014:
forum.susana.org/forum/categories/26-hea...it=12&start=24#10849

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  • Roslyn
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Re: Sanitation interventions during Ebola epidemic

I have updated the summary (see attached) of the discussions so far on Ebola and Sanitation on the SuSanA forum. This update includes:

- Update to include discussions from forum threads on the topic of Ebola up to 10.01.2015
- Restructuring and expansion of the headings
- Expansion of the links section

Thanks again Sowmya, Joe, and Arno for the several great links you’ve provided!

Roslyn

Roslyn Graham
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  • Roslyn
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Re: Question re: latrine sludge temperatures and Ebola

Hi Dan,

I've updated the summary document that Elisabeth mentioned, to reflect discussions on Ebola and Sanitation on the Forum up to 10.01.2015, see post: forum.susana.org/forum/categories/26-hea...ebola-epidemic#11558 .

In the document, I can specifically point to the sections:
  • "What information is available around the persistence of the Ebola virus in human faeces" (p. 1 and links on p. 5)
  • "Which factors need to be considered regarding handling of excreta?" (p. 2-3)
And specifically on the forum, Point #6 in Somya's post, on Ebola survival outside of the host: forum.susana.org/forum/categories/26-hea...it=12&start=24#10376

In addition to what Elisabeth has mentioned, on the platform Knowledge Point , there is also a short discussion about the survival of Ebola in the environment:
knowledgepoint.org/en/questions/2015/wha...-in-the-environment/

Roslyn

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  • joeturner
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Re: Question re: latrine sludge temperatures and Ebola

New research just published on Ebola survival in faeces:

pubs.acs.org/doi/abs/10.1021/acs.estlett.5b00029

++++++++

Note by moderator:

Inactivation of an Enveloped Surrogate Virus in Human Sewage

Lisa M. Casanova * ,
Division of Environmental Health School of Public Health, Georgia State University, Atlanta, Georgia 30302, United States
Scott R. Weaver
Division of Epidemiology and Biostatistics School of Public Health, Georgia State University, Atlanta, Georgia 30302, United States
Environ. Sci. Technol. Lett., 2015, 2 (3), pp 76–78
DOI: 10.1021/acs.estlett.5b00029
Publication Date (Web): February 23, 2015

Data are needed to provide guidance for handling of human sewage potentially containing infectious Ebola virus. The purpose of this research was to determine inactivation of enveloped viruses in sewage using bacteriophage Φ6 as a surrogate. Sewage was spiked with Φ6 and held at 22 or 30 °C, and the viral titer was measured over time. Inactivation was much more rapid at 30 °C than at 22 °C. At 30 °C, inactivation was approximately linear and reached 1.7 log10 in 24 h, 5 log10 by 48 h, and >7 log10 within 72 h. At 22 °C, the time to 5 log10 inactivation was 6 days and nonlinear. In sewage, Φ6 should be considered as a potential model for survival and inactivation of enveloped human viruses. The results suggest that enveloped viruses can undergo 6–7 log inactivation in sewage in 3–7 days, depending on temperature. Longer holding times may be desirable out of an abundance of caution at lower temperatures.

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