When Trash Becomes a Threat: Lessons in HCID Waste Management
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When high-consequence infectious diseases (HCIDs) like Ebola, Marburg virus, or Lassa fever surface, the immediate focus is on patient care. But behind the scenes, healthcare facilities face another urgent—and often overlooked—challenge: safely, legally, and efficiently managing infectious waste.
In the latest episode of Transmission Interrupted, host Jill Morgan, a nurse at Emory University Hospital and member of the Serious Communicable Diseases Program, explores this complex issue with a panel of seasoned experts:
- Jade Flinn, Principal Investigator, The Johns Hopkins Hospital Biocontainment Unit
- Ashley Perry, Director of Hazardous Waste Services, Daniels Health
- Alex Chapman, Director of Regulatory Affairs, Stericycle
- Cara Simaga, Senior Director, Regulatory Affairs, Stericycle
Together, they unpack what it takes to manage waste during a special pathogen event—from regulatory requirements and special permits to packaging, staff training, and vendor coordination. The result is a practical, comprehensive look at the systems and strategies every healthcare facility should have in place to keep staff and communities safe.
One Misstep Can Trigger a Chain Reaction
A recent case of Lassa fever in Iowa revealed how easily things can go wrong. Waste from a confirmed patient was mistakenly discarded as regular trash, ultimately contaminating compacted waste and causing costly regulatory delays, regulatory complications, and exposure concerns. More than 125 drums of Category A waste were generated—an extreme consequence of what began as a communication breakdown.
The situation is just one example of how nuanced waste classification can be. For instance, Mpox waste is generally not classified as Category A—but certain cultured forms are. That distinction can be confusing—and dangerous—if not clearly understood by everyone involved in waste handling. Misunderstandings around pathogen classification, permits, and storage can lead to serious safety, legal, and operational risks.
Category A Waste: What You Need to Know
The Department of Transportation (DOT) classifies infectious substances into three main categories:
- Category A: Pathogens that can cause severe illness or death (e.g., Ebola, Marburg, Lassa fever). These require stringent handling protocols, special permits, and specific packaging under the Pipeline and Hazardous Materials Safety Administration (PHMSA).
- Category B: These are infectious substances transported for diagnostic or investigational purposes. These have lower risk than Category A wastes and are not in a form that will cause permanent disability or death with exposure, although do require specific packaging and handling requirements.
- Regulated Medical Waste: Waste generated from the care of a patient and include less hazardous agents (e.g., HIV or Hepatitis B in a stable patient) that pose a lower risk and like Category B, do not require the same level of regulation as Category A, although do require specific packaging and handling requirements.
Most hospitals aren’t expected to be Category A waste experts—but they are expected to plan, train, and prepare to manage it effectively when the need arises.
Updated Standards, New Questions
Recent updates to The Joint Commission’s infection prevention and control standards now require accredited hospitals to demonstrate readiness to respond to special pathogen events. As a result, healthcare teams are asking important questions:
- Do we have the right documentation and permits?
- Are our containers compliant?
- Will our waste vendor accept this material?
- How do we store suspect waste safely before confirmation?
These aren’t just technical questions—they expose a widespread knowledge gap in Category A waste preparedness across healthcare.
Key Takeaways from the Field
On the podcast, experts from waste management, clinical care, and public health shared five essential lessons for HCID readiness:
1. Waste Management Is a Shared Responsibility
While Environmental Services (EVS) staff physically handle waste, everyone plays a role. Infection preventionists, clinicians, lab techs, and administrators must work together. Clear communication, proactive planning, and routine training are essential to prevent safety lapses and ensure compliance.
2. Execution of Planning Starts at First Patient Contact
Facilities must be ready to quickly identify, isolate, and manage patients who may generate Category A waste—even before diagnosis is confirmed. NETEC offers resources that can help staff quickly isolate patients, minimize waste generation, and prevent contamination.
3. Special Permits Come with Regulatory Responsibility
A single federal special permit currently covers waste from Ebola, Marburg, and Lassa fever. Under this permit, healthcare facilities are considered both waste generators and shippers—making them responsible for packaging, inactivation, documentation, and transportation compliance.
4. Coordinate Early and Often with Vendors and Public Health
Don’t wait until a patient arrives to engage your waste vendor or local health department. Share your protocols ahead of time, clarify packaging requirements, and confirm that your partners are properly permitted and understand their role in the chain of custody.
5. Treat Every Suspected Case as Category A—Until Ruled Out
Most U.S. patients evaluated for Category A illnesses are eventually diagnosed with something else—like malaria. Still, healthcare teams must be prepared to store waste securely, limit unnecessary waste generation, and consult infection prevention experts to assess what can be safely decontaminated instead of discarded.
Not Just for Hospitals
High-consequence pathogens can show up anywhere: outpatient clinics, long-term care facilities, or urgent care centers—not just major hospitals. Every point of entry into the healthcare system must be ready to handle Category A waste safely and compliantly. Need help preparing your facility? Reach out to NETEC.
The Bottom Line: Preparation Isn’t Optional
Infectious waste preparedness isn’t just about trash— it’s about protecting people, preventing exposure, maintaining compliance, and preserving public trust. With HCIDs, what you don’t know can have serious consequences.
As one expert said: “Ready or not, here it comes.” The question is—will your team be ready?
Subscribe to Transmission Interrupted at netec.org/podcast to stay ahead of evolving waste management challenges and more.
Resources for Waste Management
Handling VHF-Associated Waste (CDC, accessed 5/16/25, https://www.cdc.gov/viral-hemorrhagic-fevers/hcp/infection-control/handling-vhf-associated-waste.html)
Healthcare Waste Institute website provides links to state agencies and regulations (National Waste and Recycling Association, accessed 5/16/25, https://wasterecycling.org/healthcare-waste-institute/)
NETEC Special Pathogens Waste Management Tracer
NETEC Webinar Handle with Care
NETEC Questions to Ask Your Waste Vendor
DOT/PHMSA Planning Guidance (DoT, accessed 5/16/25, https://www.phmsa.dot.gov/transporting-infectious-substances/planning-guidance-handling-category-solid-waste)
DOT Special Permit 16279 – Ebola, Marburg, Lassa fever waste (DOT, accessed 5/16/25, https://www.phmsa.dot.gov/approvals-and-permits/hazmat/special-permits-search)
About the Experts
Alex Chapman is Director of Regulatory Affairs for Stericycle with 20 years of experience working with healthcare, commercial, and government organizations. Her work has included developing, managing, and supporting programs that drive regulatory compliance and sustainability as well as performance improvement, enablement, and education initiatives. While she has worked in a number of roles and industries, Alex’s work has primarily been in complex regulated environments with a focus on healthcare collaborating with generators, suppliers, industry organizations, and regulators to reduce risk and enhance compliant and sustainable management of waste throughout the value chain. Alex is the membership and special projects coordinator for the Healthcare Waste Institute and co-president of the Stericycle Green Team
Jade Flinn, MSN, RN, CCRN, CNRN, is the Principal Investigator for the Johns Hopkins Regional Emerging Special Pathogens Treatment Center program, Biocontainment Unit (BCU), and Director of Operations for the Johns Hopkins Special Pathogens Center. Flinn graduated from the Johns Hopkins University School of Nursing and Notre Dame of Maryland University and is trained as a neurocritical care nurse, critical care transport nurse, and nurse education leader. Flinn has been published in multiple peer-reviewed journals on the BCU team’s activities in the field of special pathogens preparedness and response including the effectiveness of steam sterilizers for infectious waste inactivation and the evaluation of the JH BCU’s activation readiness capacities.
Jill Morgan, RN, is a nurse at Emory University Hospital. She has been on Emory’s biocontainment team for over 15 years where she has cared for patients with Ebola virus disease and Lassa fever. Jill is co-lead for the PPE working group for NETEC, the National Emerging Special Pathogens Training and Education Center and has recently been appointed to the National Academies Committee on Personal Protective Equipment and Workplace Safety and Health.
Ashley Perry is the Director of Hazardous Waste Services at Daniels Health, where she leads a team focused on developing and implementing strategic initiatives around hazardous waste management and environmental compliance. She is an experienced regulatory and sustainability professional with over 12 years of work in compliance, hazardous waste, and environmental health and safety. Ashley has worked in various industries including waste treatment and agriculture, with much of her experience focused on healthcare and how to make complex compliance topics easier to understand. Ashley holds a B.A. in Environmental Policy from Cleveland State University as well as an M.S. in Sustainability from the University of Wisconsin – Green Bay.
Cara Simaga is Sr. Director of Regulatory Affairs at Stericycle. In her role, she supports the business in ensuring program and service offerings are compliant. She will celebrate 15 years with Stericycle this November and has prior experience in the hazardous waste industry. Cara was chairperson of the Healthcare Waste Institute for 3 years (2020, 2021, 2022) and is currently the regulatory liaison.