December 2, 2014 1:48 PM EST

When treating Ebola patients, hospitals have more than their patients and workers to protect. It’s their responsibility to properly dispose of anything involved in caring for the patients that might be contaminated—and that includes liquid waste, protective equipment, anything used in the lab, linens, towels, pillows, mattresses and even the curtains used in the patient’s room.

In the latest issue of the American Journal of Infection Control, John Lowe, associate director of research from the Nebraska Biocontainment Unit at the Nebraska Medical Center, describes how the team there disposed of waste generated while two patients recovered from their infections there. Some of the procedures in place, Lowe says, go beyond the guidelines set by the Centers for Disease Control and Prevention (CDC). The report will undoubtedly be studied by the 35 hospitals that the CDC designated on Dec. 2 as Ebola treatment centers across the nation.

“A number of things came up that surprised us and that we felt really needed to be shared with our colleagues,” he says.

The first of those was the sheer volume of waste generated by each Ebola patient. The group calculated that each patient treated at the Nebraska facility created about 1,010 pounds of solid waste, most of it in the form of personal protective equipment (PPE) — the hoods, face shields, suits and foot covers that doctors and nurses wear. That equipment, as well as towels and linens used for bedding, created around four to eight large bags of waste a day.

Lowe says that the group decided to treat liquid waste generated by the patients even more stringently than required by the CDC. “The lion’s share of calls we took from groups both within our facility and from outside the facility were concerns about exactly what we were doing with all that liquid waste,” he says.

CDC guidelines say that normal waste treatment chemicals in toilets are sufficient to kill Ebola. But the unit’s director Philip Smith and Lowe had two concerns. In the event that the toilets backed up, potentially infectious material could flood into the patient rooms and possibly into other pipes in the hospital as well. Public health groups also wanted assurances that the waste would not be contaminating facilities outside of the hospital. So Smith decided to take extra measures by treating the toilets in the patient’s room with hospital-grade disinfectant. Normally it takes four minutes to sterilize the waste, but to be safe, all Ebola patients’ waste was held in this sterilizing solution for 2.5 times the recommended time before it was flushed.

Flushing, says Smith, is preferable to storing the waste in a separate container and then autoclaving the contents. “You could end up having containers full of liquid that are difficult and hazardous to work with,” he says.

The bags of solid waste, meanwhile, were tied and taped closed, then doused with bleach and handled in very strict ways by workers in full PPE. The Nebraska biocontainment unit is intentionally designed to have its own decontaminating autoclave inside the unit, so soiled waste does not have to be removed from the premises. While Ebola-related waste requires special sterilization and decontamination procedures, it can be turned into normal medical waste that can be disposed of in the hopsital’s normal ways.

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To do that, health care workers send the bags into a sterilizing room. Each bag is handled at arm’s length so the workers don’t get contaminated by virus that may be on the bag and so that workers who may have virus on their PPE don’t contaminate the bags further. The bags are then treated with high temperatures and sterilizing chemicals. Once decontaminated, the bags are placed into another bag and into a watertight container and marked as biohazardous material. In this state, the waste can be disposed of as any other hospital waste in the proper medical waste removal sites.

So far, those strategies are working. Two Ebola patients, Ashoka Mukpo and Dr. Richard Sacra, were treated there and recovered, and no health care workers were infected with the virus.

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