The incidence of infectious diseases is on the rise worldwide. In addition to COVID-19 and Mpox, other infectious diseases are making headlines. In October, the University of Iowa Health Care Medical Center provided care for an individual who passed away from Lassa fever. The viral disease is rare in the U.S. but common in West Africa, where the patient had recently traveled. As of early January, CDC had confirmed 66 human cases of avian influenza A(H5), a virus responsible for outbreaks in poultry flocks and an ongoing multi-state outbreak among dairy cattle that was first identified in March 2024. As this article went to press, CDC officials were also monitoring an outbreak of Marburg virus disease, a severe viral hemorrhagic fever in the same family as Ebola, in the Republic of Rwanda and screening travelers entering the U.S. from the area. Increasing incidence of infectious diseases presents a high-stakes challenge for industrial hygienists, occupational and environmental health and safety professionals, and others involved in the mitigation and management of diseases: how to protect public and worker health while being mindful of the environmental sustainability of healthcare facilities as care and treatment needs grow.

In the U.S., facilities specializing in care for patients suspected or confirmed to be infected with high-consequence pathogens—those that can “cause serious and deadly infections and pose a significant threat to domestic and global security,” according to CDC—handled the sentinel cases of the most recent pandemic, COVID-19. These facilities, known as biocontainment care units, offer a unique way to examine ethical issues that arise during infectious disease response—specifically, ethical considerations related to roles that may be overlooked or underserved by organizations’ worker protection plans and the facilities’ environmental burden. The Synergist recently spoke with three individuals with expertise in biocontainment care about how IHs and OEHS professionals can work to balance infection control, worker health, and sustainability in these and other healthcare settings.

WHAT IS BIOCONTAINMENT CARE? Regional Emerging Special Pathogen Treatment Centers (RESPTCs) around the U.S. serve as “hubs” for biocontainment care, or high-level containment care. These specialized facilities are part of the National Special Pathogen System (NSPS), which comprises four levels corresponding to facilities’ capabilities to care for individuals with high-consequence infectious diseases. Level 4 and Level 3 facilities will likely be the ones identifying patients with infectious diseases and providing short-term care before coordinating transport to a Level 2 or Level 1 facility. Level 2 facilities can care for patients who are or may be infected by a special pathogen, or an agent that can cause severe disease, whereas Level 1 facilities have the same capabilities or greater than Level 2 facilities but also provide regional coordination and training. Level 1 facilities are part of national and global response networks.

Thirteen RESPTCs across the U.S. are designated as Level 1 facilities. According to Shawn G. Gibbs, PhD, MBA, CIH, dean of Texas A&M University School of Public Health, most Level 1 facilities are retrofitted into the locations they occupy, which means that each “is dealing with the limitations and the opportunities within their own space.” These facilities are not large; they must be able to handle up to two patients. Gibbs, who previously served as director of research for the Nebraska Biocontainment Unit in 2009–2015, says that facility is the largest Level 1 and can handle up to 10 patients, depending on the infectious disease in question and the condition of the patients. Until they are activated, Level 1 facilities serve a variety of other uses, from a recovery area for patients receiving chemotherapy to a space for training new staff to use electronic medical records. Whatever the use, these facilities must be able to be cleared out quickly so they can be turned over to handle a patient with a confirmed or suspected special pathogen, Gibbs explains.

“All of the things that make these facilities special are in the human beings that staff them, the SOPs that put them together, and the engineering that exists behind the walls,” he says. “Most of these places you walk into on a daily basis, and it looks like just another floor of a hospital.”

A COMPLICATED, CONTAMINATED ENVIRONMENT Biocontainment care settings are similar to other workplaces in that the hierarchy of controls is critical—though training and administrative controls are particularly important given the nature of the work, Gibbs says. For example, standard operating procedures (SOPs) and tabletop and operational exercises held by these facilities help keep staff ready to respond should their unit become activated. And when in use, Level 1 facilities employ all elements within the hierarchy of controls, including personal protective equipment and the administrative controls that improve PPE’s effectiveness. PPE worn in biocontainment care units may differ based on the infectious agent, condition of the patient, and the equipment that’s available, but N95 respirators, face shields, goggles, and powered air-purifying respirators (PAPRs) are among the possibilities. But while administrative controls and PPE are familiar IH concepts, the contaminated environment of a biocontainment care unit can complicate even simple tasks such as changing batteries, Gibbs says.

“Anyone can stop you and say, ‘Hey, I think you accidentally contaminated that area, so let’s pause and wipe down this area of your suit,’ or, ‘Let’s do hand hygiene,’” Gibbs says, noting that the “anyone” piece is important. All members of the team need to feel comfortable speaking up, especially since “you don’t regularly see nurses or respiratory therapists going, ‘Doctor, you need to stop because you just contaminated yourself.’”

“But that’s how important infection control is, because the first line of defense is protecting the worker, and by protecting the worker, you’re protecting the facility—you’re protecting the community,” Gibbs says.

PROTECTING ALL WORKERS Patient care is likely the first task that springs to mind when thinking about work in a biocontainment care unit. The front-line healthcare professionals in these positions, while paid, are volunteers: “They have to raise their hand and say, ‘I’m willing to go into this facility, I want to be trained to work with these types of patients, and I understand the risk,’” Gibbs says. But additional workers may be responsible for waste management, custodial, and janitorial tasks. Like healthcare professionals, environmental service workers are at increased risk of exposure to pathogens that cause infectious diseases, especially when they are involved in cleaning or decontamination.

At the core of infectious disease response is the ethical commitment to protect health and safety, stresses Abigail (Abbey) E. Lowe, MA, PhD, a bioethicist. Lowe is an associate professor in the University of Nebraska Medical Center College of Public Health and a scholar at the university’s Global Center for Health Security, which focuses on managing high-consequence infections. GCHS is home to the largest biocontainment unit in the U.S. as well as the National Quarantine Unit, the only quarantine unit funded by the federal government. According to Lowe, this commitment calls for IHs, OEHS professionals, and other responsible parties to safeguard patients, healthcare workers, and support staff, and work to prevent broader community transmission of infectious diseases.

“In biocontainment care settings, maintaining strict infection control protocols, such as using appropriate PPE and enforcing rigorous training programs, embodies this principle,” Lowe says.

Though exposure risk is shared among different worker groups, what may not be equitable is the distribution of risk based on workers’ training, experience, and compensation, says Aurora B. Le, PhD, MPH, CIH, CSP, CPH, an associate professor of health behavior at Texas A&M University School of Public Health. Le previously served alongside Gibbs in 2015–2016 as a research assistant for the Nebraska Biocontainment Unit and helped develop a training curriculum on the management of highly infectious remains. Le and Gibbs shared that as part of the Nebraska Biocontainment Unit’s voluntary staffing model, healthcare workers cleaned and did decontamination when the site was activated during the Ebola outbreak. In contrast, Le has volunteered in a different healthcare setting where environmental service workers were responsible for decontaminating a room after it was used to treat an active tuberculosis patient. For Lowe, these experiences underscore what ethicists refer to as the value of reciprocity. In this case, reciprocity includes the mutual obligations between society, employers, and workers in addressing the risks associated with infectious diseases.

“Workers who place themselves at heightened risk, including environmental service workers, waste handlers, and healthcare staff, deserve equitable protection, fair compensation, and access to comprehensive training,” Lowe explains.

The level of protection afforded to populations like environmental service workers and waste handlers depends on how staff are structured and how proactive hospital management is in addressing infection control and other exposure concerns for these groups, Le says. Gibbs adds that some hospital systems use contract environmental service workers, and in some cases labor union contracts may specify who is and is not allowed to perform certain tasks. Laws and regulations that govern the locale of a facility can also affect protections for environmental service workers and others.

According to Lowe, gaps in protections and training can emerge in facilities where contract workers perform critical decontamination tasks. An AMA Journal of Ethics article authored by Lowe and Gibbs on protecting personnel in environmental services and related fields in healthcare settings shows how contracts can be a barrier to protecting these workers. As explained in the article, the contractor status of some environmental service workers “can entail receiving lower pay and not having their health and safety needs prioritized.”

“Public health ethics demands that organizations acknowledge these vulnerabilities and take proactive measures to reduce disparities,” Lowe says. “This includes extending adequate PPE, providing hazard pay, and ensuring fair labor practices that reflect the risks these workers assume to protect others.”

In a fictional scenario outlined in the article, a novel strain of airborne-transmissible influenza is affecting the U.S. The physician overseeing a hospital’s infection prevention and control protocols discovers that the contract with its waste management firm only requires the hospital to provide gloves for these workers, who enter hospital rooms to empty biohazardous containers. But additional PPE—N95 respirators—are needed to provide appropriate protection for the workers from the new pathogen. With the hospital’s supply unable to cover the firm’s workers, and the firm unable to secure an N95 supplier due to shortages, this case highlights what can go wrong when organizations take a reactive approach to implementing protections for environmental service and related workers. Similarly, the COVID-19 pandemic brought to the forefront ethical issues related to workers deemed essential during an infectious disease emergency.

“A lot of people had to continue to work on the front lines of an infectious disease pandemic without some of the infection prevention and control considerations that had been afforded to the healthcare sector,” says Lowe. Meat processing workers, for example, found themselves working in communities that were early hot spots of COVID-19, which Lowe describes as a “perfect storm of health disparity” in a population involved in work that was hazardous even before the addition of infectious disease.

Le adds that when it comes to infectious diseases, some workplaces are stretched so thin that they’re only going to do what’s absolutely required of them, which may amount to simply following the bloodborne pathogen standard and providing refresher training to workers. Many employers don’t realize that there are federally sponsored resources for training workers in a variety of topics, including infectious diseases—for example, those offered under the National Institute of Environmental Health Sciences (NIEHS) Worker Training Program (learn more about these resources in the September 2024 Synergist). IHs and OEHS professionals are in a position to help workers find credible sources for training and education, including the many public resources published by AIHA, Le says.

“If people aren’t in a workplace where their employer can provide that resource to them—or are willing to—then I feel like we as professionals have the responsibility to make sure that workers are at least realizing that they can have access [to this information] and it’s not going to cost them anything.”

In terms of high-consequence infectious diseases, Lowe emphasizes the “reciprocal obligation that we have as a society to protect workers, no matter where they land on the continuum of care,” whether they are working in a biocontainment unit or taking on risk elsewhere on the front lines.

PRODUCT STEWARDSHIP AND SUSTAINABILITY CONSIDERATIONS Between the PPE needed to protect workers and the materials necessary to care for patients infected with high-consequence pathogens, there is the potential for biocontainment units and related healthcare settings to generate significant waste, pollution, and burden on the environment. According to Gibbs, many people involved with these facilities want to dispose of everything a patient might have touched, which he sees as a natural reaction to dealing with some of the deadliest microorganisms and illnesses on the planet.

“But not everything has to contribute to the waste stream,” Gibbs says. “The truth of the matter is, at the end of the day, these are viruses, and we know how they behave in the environment—we know that they decay over time.”

A small-scale example is if an infected person were wearing a ring, would his team need to discard it? Gibbs says no. One way to decontaminate the jewelry might be to drop it in bleach for 10 minutes, dry it out, then put it under UV light. On a larger scale, biocontainment units use clinical laboratory equipment as diagnostic and monitoring tools for patients who are confirmed or suspected to be infected with high-consequence pathogens. Some point-of-care devices might be in the room, or samples might be taken to a clinical laboratory for analysis. Either way, Gibbs stresses that clinical laboratory equipment doesn’t have to be disposed of; it can be cleaned and decontaminated. But manufacturers lack sufficient guidance for how to decontaminate equipment after it’s been used to evaluate specimens containing a high-consequence pathogen, according to an August 2024 letter to the editor of Infection Control & Hospital Epidemiology coauthored by Le and Gibbs. The letter refers to a 2019 article published in Public Health Reports that urged manufacturers of clinical laboratory equipment to develop standard protocols for testing specimens during response to highly hazardous communicable diseases and for decontaminating equipment.

IHs and OEHS professionals are also instrumental in PPE selection. PPE ensembles selected for biocontainment care ideally provide the most flexibility in terms of the pathogens workers may face. Maximum comfort is another key consideration. Gibbs notes that it’s also important for workers to train in the same PPE they’ll don when the facility is activated, likening the process to athletes practicing in the same equipment they wear on game day. Like laboratory equipment, some PPE can be reused effectively. How much reusable PPE a healthcare facility might use depends on protection needs, budget, and how well employees are trained to properly decontaminate equipment, Le says. The status of the supply chain also factors into PPE selection, Gibbs adds, pointing to the early days of COVID-19 when scarcity and emergency pushed facilities across the U.S. to decontaminate and reuse N95 filtering facepiece respirators, which are labeled as single-use, disposable devices.

During a pandemic, Le expects the general public to mostly use disposable PPE. While this contributes to some landfill waste and environmental pollution, Le explains that it’s the tradeoff for getting the public to take some protective action using PPE. The budgets of hospitals and other healthcare facilities exceed the funds available to the general public, meaning healthcare organizations are likely more able to purchase reusable PPE. Healthcare settings are also better equipped to care for reusable equipment, Le says: they have cleaning and disinfection products containing quaternary ammonias and bleach, and they have facilities where PPE can be stored while it’s being turned over for reuse. She encourages hospitals to consider reusable PPE as a kind of counterbalance to disposable PPE used by the public and in other settings: in this way, they’re “not only being stewards of healthcare, but also being stewards of the environment.” But Le understands that there’s no perfect answer for any facility.

“They have to really think about the long-term return on investment of the initial purchase of reusable PPE and training people and have it be efficacious versus constantly having to restock disposable PPE that is going to cause additional environmental burden,” she explains.

Lowe believes that RESPTCs can help drive “important innovations that should be happening around PPE”—for example, advances related to reusable PPE and sustainability that could help mitigate the effects of shortages of disposable products during a future pandemic. “We could also think about how [such developments might] translate to other industries with workers we know need infection prevention and control and PPE in the event of an outbreak,” Lowe adds.

Biocontainment care settings inevitably generate waste, as not all equipment is able to be reused or reprocessed. And depending on the type of organism and illness, a significant amount of waste will have to be disposed of as highly infectious Category A waste, Gibbs says. This is an “inherent weakness nationally” because there are not enough facilities in the U.S. that can handle, process, and dispose of Category A waste, he explains. (Further discussion on this topic can be found in a commentary authored by Gibbs et al. and published in January 2024 in the American Journal of Infection Control.) Because it is expensive, time-intensive, and resource-intensive to dispose of Category A waste, Gibbs stresses that waste reduction is a key step that must take place before supplies and equipment enter a biocontainment care unit.

“The more that you can pull out in normal environments and recycle, or get into the normal waste stream or the normal recycling or reprocessing stream of the hospital, the better for the environment,” Gibbs explains. “And it’s safer for the workers in the facility because they’re not trying to use a box cutter to open up boxes or fiddle around with packaging while in the biocontainment unit.”

LOOKING AHEAD The 13 Level 1 biocontainment facilities in the U.S. represent the gold standard of care for patients with high-consequence infectious diseases, and Gibbs, Le, and Lowe feel that they model well how facilities should approach worker protection, sustainability, and product stewardship. But the reality is that most healthcare settings do not have access to the same level of resources, and other facilities must figure out what they can do within the limitations of their budget, Le notes. Another challenge is funding’s tendency to dry up during periods when infectious diseases are perceived to “quiet down” between outbreaks. For example, centers involved with addressing the threat of Ebola in the U.S. were defunded or deactivated not long before the beginning of the COVID-19 pandemic. Le is concerned that the U.S. is becoming complacent rather than relying on sustained basic principles of protection, even as H5N1, Mpox, and other infectious diseases continue to spread among animals and people.

Lowe views biocontainment care settings as thoughtful in their approach to protecting all workers but sees a wide gap when it comes to protecting workers outside of these specialized facilities. The regional treatment centers are important resources that provide critical care for high-consequence infectious disease patients, she says. But when pathogens are unable to be contained and begin to spread, Lowe points out that we haven’t made many changes following previous pandemics—from influenza in 1918 to swine flu in 2009 to COVID in 2019—to help protect workers outside of healthcare against infectious diseases.

“This is not a new story, but prioritizing equity [across worker populations] does require certain policy choices that are not in place,” she says. When there isn’t funding to develop evidence-based protections for high-consequence infectious diseases for other built environments, “lots of workers are having to do their best to practice infection prevention and control.”

IHs and OEHS professionals and volunteers from organizations like the NIEHS Worker Training Program are among those working on bottom-up solutions to more broadly address infection prevention and control in all workplaces. Absent policy changes and sufficient funding at the federal level, say Le and Lowe, individuals and the organizations they’re involved with will be “swimming against the tide” to help improve worker protections and develop more sustainable approaches to providing care for infectious diseases.

KAY BECHTOLD is managing editor of The Synergist.

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