&EPA
United States
Environmental Protection
Agency
EPA/600/R-16/054 | May 2016
vvww.epa.gov/homeland-security-research
Collaborative Workshop on Handling,
Management, and Treatment of High-
Consequence Biocontaminated Wastewater
by Water Resource Recovery Facilities
Office of Research and Development
National Homeland Security Research Center
-------
WERF7W15
Collaborative Workshop on Handling,
Management, and Treatment of High-
Consequence Biocontaminated
Wastewater
by Water Resource Recovery Facilities
WORKSHOP SUMMARY REPORT
2016
XWERF
-------
The Water Environment Research Foundation, a not-for-profit organization, funds and manages water quality research for its
subscribers through a diverse public-private partnership among municipal utilities, corporations, academia, industry, and the
federal government. WERF subscribers include municipal and regional water and water resource recovery facilities,
industrial corporations, environmental engineering firms, and others that share a commitment to cost-effective water quality
solutions. WERF is dedicated to advancing science and technology, addressing water quality issues as they impact water
resources, the atmosphere, the lands, and quality of life.
For more information, contact:
Water Environment Research Foundation
635 Slaters Lane, Suite G-110
Alexandria, VA 22314-1177
Tel: (571) 384-2100
Fax: (703) 299-0742
www.werf.org
werf@werf.org
© Copyright 2016 by the Water Environment Research Foundation. All rights reserved. Permission to copy must be obtained
from the Water Environment Research Foundation.
This report was prepared by the organizations) named below as an account of work sponsored by the Water Environment
Research Foundation (WERF). Neither WERF, members of WERF, the organizations) named below, nor any person acting
on their behalf: (a) makes any warranty, express or implied, with respect to the use of any information, apparatus, method, or
process disclosed in this report or that such use may not infringe on privately owned rights; or (b) assumes any liabilities with
respect to the use of, or for damages resulting from the use of, any information, apparatus, method, or process disclosed in
this report.
The United States Environmental Protection Agency/National Homeland Security Research Center managed and collaborated
in this research under EPA agreement number EP-15-C-000124. It has been subjected to the Agency's review and has been
approved for publication. Note that approval does not signify that the contents necessarily reflect the views of the Agency.
Mention of trade names, products, or services does not convey official EPA approval, endorsement, or recommendation.
This document was reviewed by a panel of independent experts selected by WERF. Mention of trade names or commercial
products or services does not constitute endorsement or recommendations for use. Similarly, omission of products or trade
names indicates nothing concerning WERF's or EPA's positions regarding product effectiveness or applicability.
The discussion and recommendations in this document do not rely on and do not affect authority under the Comprehensive
Environmental Response, Compensation, and Liability Act (CERCLA), 42 U.S.C. 9601 et seq., the Clean Water Act, 33
U.S.C. §1251 et seq., the National Contingency Plan (NCP), 40 CFR Part 300, or any other rule. This document is intended
to provide information and suggestions that may be helpful for implementation efforts and should be considered advisory.
The discussions and recommendations in this document are not required elements of any rule. Therefore, this document does
not substitute for any statutory provisions or regulations, nor is it a regulation itself, so it does not impose legally-binding
requirements on EPA, states, or the regulated community. The recommendations herein may not be applicable to each and
every situation.
ii
XWERF
-------
About WEMF
The Water Environment Research Foundation, formed in 1989, is America's leading independent
scientific research organization dedicated to wastewater and stormwater issues. Throughout the last 27
years, we have developed a portfolio of more than $134 million in water quality research.
WERF is a nonprofit organization that operates with funding from subscribers and the federal
government. Our subscribers include wastewater treatment facilities, stormwater utilities, and regulatory
agencies. Equipment companies, engineers, and environmental consultants also lend their support and
expertise as subscribers. WERF takes a progressive approach to research, stressing collaboration among
teams of subscribers, environmental professionals, scientists, and staff. All research is peer reviewed by
leading experts.
For the most current updates on WERF research, sign up to receive Laterals, our bi-weekly electronic
newsletter.
Learn more about the benefits of becoming a WERF subscriber by visiting www.werf.org.
Collaborative Workshop on Handling, Management, and Treatment of Biocontaminated Wastewater
by Water Resource Recovery Facilities
iii
-------
ACKNOWLEDGMENTS
Special thanks to Bill Cooper of the National Science Foundation (NSF) and representatives of the
Occupational Safety and Health Administration (OSHA).
Report Preparation
Anne Sundermann
Morning Sun Editorial Services, Inc.
Carrie W. Capuco, JD
Water Environment Research Foundation
Water Environment Research Foundation Staff:
Director of Research: Amit Pramanik, Ph.D., BCEEM
Program Director: Lola Olabode, M.P.H.
iv
XWERF
-------
TABLE OF CONTENTS
Acknowledgments iv
List of Acronyms vii
Executive Summary ES-1
1.0 Introduction 1-1
2.0 Perspectives on Biocontaminated Wastewater 2-1
2.1 Government Perspectives 2-1
2.1.1 U. S. Environmental Protection Agency (EPA) 2-1
2.1.2 Occupational Safety and Health Administration (OSHA) 2-3
2.1.3 Department of Homeland Security - Protective Security Advisors (PSA).. 2-3
2.2 State/City/Region Experience, Lessons Learned, and Current Process 2-4
2.2.1 Metropolitan Washington Council of Governments (MWCOG) 2-4
2.2.2 New York City Department of Environmental Protection 2-4
2.3 Utility and Other Stakeholder Perspective 2-4
3.0 Needs and Requirements for Accepting Biocontaminated Wastewater 3-1
3.1 Accurate and Available Scientific Data 3-1
3.2 Coordination between Agencies 3-2
3.3 Readiness and Notification Protocols 3-3
3.4 Response Timeline 3-3
3.5 Characterization of the Biocontaminant(s) 3-3
3.6 Administrative and Financial Issues for Utilities 3-4
4.0 Tests, Protocols, and Guidelines for Accepting Waste 4-1
4.1 Tests and Protocols 4-1
4.2 Monitoring and Analysis 4-2
4.3 Existing Guidelines and Guidance 4-3
4.3.1 Medical Waste Disposal Guidelines 4-3
4.3.2 Biohazardous Spill Clean Up Guidelines 4-3
4.3.3 WERF Guidance Document 4-3
4.3.4 Quality Assurance Project Plan - Pathogen Equivalency Committee 4-4
4.4 Interconnect vity 4-4
4.5 Jurisdiction 4-5
4.6 Regulatory Framework 4-5
4.7 Permitting Authorities 4-6
4.8 Design and Implementation 4-6
5.0 Safety and Health Concerns 5-1
5.1 Exposure - Workers 5-1
5.2 Training 5-3
5.2.1 Personal Protective Equipment (PPE) Training 5-3
5.2.2 Hazardous Materials Training 5-4
5.2.3 Incident Training 5-4
5.3 Transmission Risk 5-4
6.0 Communications 6-1
Collaborative Workshop on Handling, Management, and Treatment of Biocontaminated Wastewater
by Water Resource Recovery Facilities
v
-------
7.0 Data Gaps and Research Needs 7-1
7.1 Unified Guidelines 7-1
7.2 Characterization of Biocontaminants 7-2
7.3 Understanding and Preventing Worker Exposure 7-3
7.4 Management of Post-Treatment Impacts 7-3
8.0 Summary Statements and Next Steps 8-1
Appendix A A-l
Appendix B B-l
Appendix C C-l
Bibliography and Further Reading R-l
XWERF
-------
LIST OF ACRONYMS
AFIT Air Force Institute of Technology
AOP Advanced oxidation process
BSL Biosafety level
CBR Chemical, biological, and radiological
CDC Centers for Disease Control and Prevention
CERCLA Comprehensive Environmental Response, Compensation,
and Liability Act of 1980, as amended
CSO Combined sewer overflow
CWA Clean Water Act, as amended
DEP Department of Environmental Protection
DHS U.S. Department of Homeland Security
EOP Emergency operation plan
EPA U.S. Environmental Protection Agency
EWS Early Warning System
FIB Fecal indicator bacteria
GWRS Groundwater replenishing system
HHS U.S. Department of Health and Human Services
NHSRC EPA's National Homeland Security Research Center
ISCORS Interagency Steering Committee on Radiation Standards
MSDGC Metropolitan Sewer District of Greater Cincinnati
MWCOG Metropolitan Washington Council of Governments
NAICS North American Industry Classification System
NCP National Contingency Plan
NIH National Institutes of Health
NIOSH National Institute for Occupational Safety and Health
NSF National Science Foundation
OP Organophosphate
OWM EPA's Office of Wastewater Management
OSHA Occupational Safety and Health Administration
PCR Polymerase chain reaction
PEC Pathogen Equivalency Committee
PIMW Potentially infectious medical waste
POTW Publicly owned treatment works
PPE Personal protective equipment
Collaborative Workshop on Handling, Management, and Treatment of Biocontaminated Wastewater
by Water Resource Recovery Facilities
vii
-------
PSA
Protective security advisor
PVC
Polyvinyl chloride
QA/QC
Quality assurance/quality control
QAPP
Quality assurance project plan
RCRA
Resource Conservation and Recovery Act
SDWA
Safe Drinking Water Act, as amended
SME
Subject matter expert
SOP
Standard operation procedure
Sub-IPC
Sub-Interagency Policy Committee
T&E
Test and evaluation
TSDF
Treatment, storage, and disposal facility
VSAT
Vulnerability self-assessment tool
WERF
Water Environment Research Foundation
WH NSC
White House National Security Council
WLA
Water Laboratory Alliance
WRF
Water Research Foundation
WSD
EPA's Water Security Division
WRRF
Water resource recovery facility
WW TP
Wastewater treatment plant
via
XWERF
-------
Executive Summary
The Water Environment Research Foundation (WERF), in partnership with the U.S. Environmental
Protection Agency (EPA) National Homeland Security Research Center (NHSRC) and the National
Science Foundation (NSF), hosted an expert workshop on November 17 and 18, 2015, in Alexandria,
Virginia, to engage with subject matter experts and wastewater utility stakeholders on a number of
topics surrounding high consequence pathogens in wastewater collection and treatment systems, should
such pathogens enter the systems as a result of an emergency situation. The workshop included
presentations and discussion on topics such as:
~ What is neededfor utilities to accept biocontaminated wastewaters?
~ What types of tests and protocols are needed (and what is the design for such tests)?
~ What is neededfor permit authorities to guide / allow utilities to accept these wastes?
~ What is needed to address concerns and issues raised by the public, by workers and operators?
~ What are the gaps and what types of research are needed?
The workshop participants determined that there are data gaps and research needs for four broad
concerns or issues with accepting biocontaminated wastewater:
~ Need for a unified, sole-source guidelines
~ Characterization of biocontaminants
~ Understanding and preventing worker exposure
~ Management of post-treatment impacts
After a general discussion of future needs, suggestions, logistics, and guidelines, the participants created
the following summary statements which contain suggested next steps for helping utilities prepare for
issues related to biocontaminated wastewater.
What is needed for
utilities to accept
biocontaminated
wastewaters?
Credible suggestions that utility workers, treatment processes, and communities
will not be adversely impacted by the biocontaminant(s) in question. These
suggestions should be provided by an interagency, interdisciplinary workgroup
(including industry and government experts, EPA, Centers for Disease Control
and Prevention (CDC)/National Institute for Occupational Safety and Health
(NIOSH), OSHA, and others).
Next step action: In cooperation and coordination with the interagency group,
develop a state of the science assessment for utility response.
Next step action: In cooperation and coordination with the interagency group,
develop a utility response plan.
Other considerations: additional worker safety information; communication that
is coordinated and contains unified information; learning from Interagency
Steering Committee on Radiation Standards (ISCORS) analysis in the face of
limited funding and laboratory capacity; recognition that the issue is of national
significance; understanding that there will be gaps in knowledge for
biocontaminant survivability in wastewater; unanticipated, incident-specific
indemnity issues for utilities associated with their implementation of the utility
response plan developed above; acknowledgment of the differences of the
utilities in response.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
ES-1
-------
What types of tests and
protocols arc needed
(and what is the design
for such tests)?
Appropriate assays, surrogates, and diagnostic tools, etc., to determine the
infectivity, persistence and fate of Bacillus anthracis and other high consequence
pathogen(s) of interest.
Next step action: Beyond Bacillus anthracis, develop an interagency,
interdisciplinary workgroup (including industry and government experts, EPA,
CDC/NIOSH, OSHA, and others) to evaluate a suite of potential, high-
consequence pathogenic organisms that may be introduced into wastewater.
What can be done now
to start regulatory
planning for the proper
management of
biocontaminated
wastewater?
Cascading authority should be aligned from the federal level down to the state
and local level and integrated into existing U.S. Department of Homeland
Security (DHS) or new frameworks.
Consensus (shared risk) between regulators and utility operators/owners.
Relationships built pre-incident between incident responders and wastewater
utility personnel.
What is needed to
address concerns and
issues raised by the
public, workers, and
operators?
Technical and non-technical information that is clear, acknowledges uncertainty,
and is geared to appropriate audiences.
Communication and emergency toolkits.
What are the gaps and
what types of research is
needed?
Synthesis of existing global data to identify gaps and develop information on
survivability, persistence, fate, viability, etc., across all media and processes;
worker exposure; sampling analysis/optimization; as well as risk assessment.
Real-time monitoring, robust analytical methods and techniques, development of
technologies.
ES-2
XWERF
-------
CHAPTER 1.0
Introduction
In November 2015, the U.S. Environmental Protection Agency (EPA) National Homeland
Security Research Center (NHSRC), the National Science Foundation (NSF), and the Water
Environment Research Foundation (WERF) held a workshop that provided an opportunity for
wastewater sector representatives, subject matter experts (SMEs), and regulatory representatives to
discuss scenarios where high-consequence pathogens, in particular Bacillus anthracis (anthrax) spores,
could be introduced, intentionally or inadvertently, into the wastewater collection and treatment system.
The scenarios examined were based on biocontaminated waste entering a wastewater collection and
treatment system in two main ways, namely:
~ Direct introduction of a pathogen, either accidentally or intentionally, into the wastewater collection
system, so that the water resource recovery facility (WRRF) is unaware that it has been introduced.
~ With the WRRF's knowledge, wastewater treated for a pathogen of interest enters the collection
system, e.g., via discharge of decontaminated water into the collection system, as a result of a
decontamination operation within the WRRF itself, etc.
The National Science Foundation through its Environmental Engineering Program
Division of Chemical, Bioengineering, Environmental, and Transport Systems encourages
transformative research that applies scientific and engineering principles to avoid or minimize solid,
liquid, and gaseous discharges, resulting from human activities on land, inland and coastal waters, and
air, while promoting resource and energy conservation and recovery. The program also fosters cutting-
edge scientific research for identifying, evaluating, and monitoring the waste assimilative capacity of the
natural environment and for removing or reducing contaminants from polluted air, water, and soils.
The NHSRC conducts research to detect, respond to, and recover from major disasters resulting
from all types of hazards, both unintentional (e.g. natural disasters, industrial accidents, etc.) or
intentional (e.g. criminal activities, terrorist attacks, etc.). The EPA has been conducting research on
ways to prevent, detect, contain, and treat contaminants in water and wastewater and is also producing
tools and procedures for decontamination. All of this work is being performed with input from EPA's
primary water security stakeholders. NHSRC is currently investigating what research gaps exist to help
guide wastewater plant operators to decide whether and how to accept some or all wastewater
contaminated with high-consequence pathogens as a result of an emergency situation. More information
on EPA's homeland security research program can be found at www.epa.gov/hsresearch (last accessed
March 23, 2016).
This workshop, facilitated by WERF, is the third in a series of similar workshops conducted by
WERF for NHSRC and will focus on biological contamination impact on WRRFs, previously known as
Publicly Owned Treatment Works (POTWs) or Wastewater Treatment Plants (WWTPs), including
collection systems. The first two workshops dealt with chemical and radiological contaminants, and
summary reports are available (Project numbers WERF3W11 and WERF1W12, respectively; see also
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
1-1
-------
https://cfpub.epa.gov/si/si public file download.cfm?p download id _ 59 last accessed March 23,
2016).
The background of this workshop is that in 2013, EPA's Region 4 (Southeast United States)
Weapon of Mass Destruction Committee wanted to know what states in the region would do with
wastewater contaminated with anthrax spores. Wastewater disposal had been an issue in previous EPA
anthrax responses, and there was no finalized guidelines on this topic. Interim draft guidelines was
issued in 2003 (and updated in 2005) by the U.S. National Response Team, including an Appendix
entitled "Guidelines for discharging anthrax decontamination wastewater to publicly owned treatment
works (POTWs)." Because much may have changed in the past decade, in October 2014, NHSRC
organized a meeting hosted by the City of Raleigh (North Carolina) to identify the needs and issues
relevant to the wastewater contaminated with biological agents. The suggestions from this meeting led
to the workshop, described in this report, to address the following key objectives:
1. Identify what is needed/required for utilities to accept biocontaminated wastewaters.
2. Specifically identify the appropriate tests, protocols, and regulatory guidelines required for design
and/or implementation of acceptance procedures. For example, what is needed for permit authorities
to guide/allow utilities to accept biocontaminated wastes?
3. Identify what is needed to address concerns and issues raised by the public, wastewater workers, and
operators.
4. Understand the research needs from the national perspective using lessons learned from affected
regions, states and/or cities as a starting point.
5. Describe the research data gaps in detail.
6. Gather input from the wastewater sector on what research experiments would be most appropriate to
generate results that WRRFs can utilize when faced with intentionally or unintentionally receiving
biocontaminated wastewater, particularly when the contaminant is spores.
Participants arrived at the workshop prepared to discuss several key questions regarding bio-
contaminants in wastewater treatment systems. Meeting materials and other information, such as the
participant list and agenda, are included in the Appendices to this report. Electronic versions of the
presentations (Appendix C) by participants are available from WERF upon request. The key questions
were:
~ What is needed and/or required for utilities to accept biocontaminated wastewaters?
~ What types of tests and protocols and regulatory guidelines are needed?
~ What is needed for permit authorities to guide/allow utilities to accept these wastes?
~ How should tests, protocols, and regulatory guidelines be designed or implemented?
~ Who should design and evaluate these?
~ What are the physical, logistical, and requirement constraints in design and implementation?
~ Are there other "simpler" tests and protocols?
~ What is needed to address concerns and issues raised by the public, workers, and operators?
~ What other concerns need to be addressed?
~ What are the data gaps and what type of research (including experimental scale) is needed?
1-2
"HWERF
-------
This report summarizes key points of the information shared and the discussion during the workshop. It
also outlines data gaps, future needs, and suggestions. Four overarching concerns, or issues, with
accepting bio-contaminated wastewater were identified:
1. Unified, sole-source guidelines
2. Characterization of bio-contaminants
3. Worker exposure
4. Post-treatment impacts
To better highlight research gaps and suggest actions, the workshop participants developed
summary statements for the following questions; data gaps and research needs associated with each of
these broad issues were also identified.
~ What is needed for utilities to accept bio-contaminated wastewaters?
~ What types of tests and protocols are needed (and what is the design for such tests)?
~ What is needed for permit authorities to guide/allow utilities to accept these wastes?
~ What is needed to address concerns and issues raised by the public, by workers and operators?
~ What are the gaps and what types of research is needed?
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
1-3
-------
-------
CHAPTER 2.0
Perspectives on Biocontaminated Wastewater
To explore the range of perspectives on bio-contaminated* wastewater, the workshop organizers
invited participants with a broad range of expertise. The invitees also represented an array of
organizations, all of which brought a unique perspective to the discussion. To familiarize all participants
with each other's perspectives, participants presented information related to their organization, including
testing and evaluation, limits of implementation and capabilities. Specific incidents, if any, were
presented, as well as public communication strategies and examples of regulatory and research gaps. It
should be noted that all perspectives presented were those of the individual, not the formal perspective
of the organization or agency of the workshop participant. The titles of the participants' presentations
are listed in Appendix C, and copies of the presentations are available from WERF upon request.
To put the range of perspectives in context, biocontaminated waste was considered to enter a
wastewater collection and treatment system in two main ways, namely:
~ Direct introduction of a pathogen, either accidentally or intentionally, into the wastewater collection
system, so that the WRRF is unaware that it has been introduced.
~ With the WRRF's knowledge, wastewater that has been treated for a pathogen of interest enters the
collection system, e.g., via discharge of decontaminated water into the collection system, as a result
of a decontamination operation within the WRRF itself, etc.
While most of the perspectives presented below are relevant to both broad scenarios, workshop
participants chose to focus mostly on the second, viewing the introduction without their knowledge as
falling under the same "Act of God", "Force majeure "force of nature", or similar category that limits
their legal responsibility in planning for them. This approach is similar to a natural disaster rendering
their system non-operational. Certainly, the first scenario may create conditions within their system that
they should deal with technically, and the participants' perspectives on these are discussed below.
However, the second imposes more complex, non-technical requirements on the participants'
organizations.
2.1 Government Perspectives
Representatives from a variety of federal agencies that have oversight over, responsibility for, or
interest in the issue of biocontamination summarized their perspectives and/or organizational
background as follows.
*For the purpose of this Workshop, participants were informed that "biocontaminated wastewater" contains high-consequence
pathogens (e.g., bacteria, including spores as well as viruses and other pathogens) that are introduced into wastewater either
intentionally (e.g., with malicious or criminal intent through managed discharge) or inadvertently (e.g., accidental or
unintended discharge resulting from natural disasters, disease outbreak, etc.).
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
3-1
-------
2.1.1 Environmental Protection Agency Water Sector infrastructure, which consists of drinking
water and wastewater systems, has a long history of implementing programs to provide clean and safe
water, thereby protecting public health and the environment across the Nation. For more than thirty (30)
years, drinking water and wastewater utilities have been conducting routine daily, weekly, and monthly
water quality monitoring under guidelines of the Safe Drinking Water Act (SDW A) and Clean Water
Act (CWA). Researchers continue to explore ways to improve water quality testing methods. Together,
the sector's public health, environmental, security, and resilience efforts form a multi-layered approach
to provide clean, safe drinking water and protect public health.
Homeland Security Presidential Directive 7 designates the U.S. Environmental Protection
Agency (http ://www.epa.gov/, last accessed March 23, 2016) as the Federal lead for coordinating and
assisting in protecting the Nation's critical Water Sector infrastructure. It is necessary to better protect
Water Sector infrastructure to safeguard public health and the economic vitality of the Nation. Malicious
acts, natural disasters, and denial of service that affect the sector could result in large numbers of
illnesses or casualties, as well as negative economic impacts. Critical services such as firefighting and
health care (hospitals), to include other dependent and interdependent sectors such as energy,
transportation, and food and agriculture, would suffer damaging effects from a denial of potable water or
properly treated wastewater.
2.1.1.1 Office of Water/Office of Ground Water and Drinking Water/Water Security Division
(WSD)
WSD (https://www.epa.gov/waterresilience/basics-water-resilience, last accessed March 24 2016
2016) provides information to help water and wastewater utilities: 1) Assess and reduce vulnerabilities
to potential terrorist attacks; 2) Plan for and practice response to emergencies and incidents; 3) Develop
new security technologies to detect and monitor contaminants and prevent security breaches. It is
important for drinking water and wastewater utility managers, board members, and elected and
appointed officials to understand the benefits of investing in preparedness, prevention and mitigation
activities at the utility. This information covers topics including risk assessment, emergency response,
recovery, training, and water quality surveillance (https://www.epa.eov/waterresilience. last accessed
March 24, 2016).
2.1.1.2 Office of Wastewater Management (OWM)
OWM (http://www.epa.gOv/aboutepa/about-ofrice-water#wastewater. last accessed March 24,
2016) oversees a range of programs contributing to the well-being of the nation's waters and watersheds.
Through its programs and initiatives, OWM supports the federal Water Pollution Control Act,
commonly known as the Clean Water Act, by promoting effective and responsible water use, treatment,
disposal and management and by encouraging the protection and restoration of watersheds.
2.1.1.3 Office of Research and Development/National Homeland Security Research Center
NHSRC (http://www.epa.gov/homeland-seciirity-research. last accessed March 24, 2016)
supports EPA's homeland security responsibilities in a variety of areas, including wastewater systems,
outdoor areas, and buildings. Its research strategy is designed to meet the following objectives: 1)
improve water utilities' abilities to prepare for and respond to incidents that threaten public health; and
2) advance EPA's capabilities to respond to wide-area contamination incidents. NHSRC responsibilities
are related to improving resilience to disasters. "Resilience" is currently a popular term; in this instance,
it is used to define how communities recover after a disaster.
3-2
XW ERF
-------
NHSRC is an applied program and as such, uses a systems approach and includes interactions
between different phases and components (see Figure 2-1). NHSRC seeks to avoid unintended
consequences and values interaction with stakeholders to help meet needs and assist with decision
making. The mission of NHSRC is to conduct research and develop scientific products that improve the
capability of the Agency to carry out its homeland security responsibilities.
Applied HS Research: Systems Approach
Increasing resilience
Reduce
Vulnerabilities
Lessons Learned and
Preplanning
Wastewater
treatment
(including
wash water)
Remediation or
Decon
Decontamination of
water infrastructure
& water treatment
(including premise
plumbing)
Cyber security for water systems
On-line monitoring
of contaminants in
drinking water
systems
Contaminant fate
and transport
Characterization &
Risk Assessment
Sampling and analysis for
water and wastewater
Figure 2-1. EPA's Homeland Security Research Center Uses a Systems Approach to its Research.
2.1.1.4 Pathogen Equivalency Committee (PEC)
The Pathogen Equivalency Committee (http://www.epa.gov/biosolids/pathogen-equivalencv-
committee. last accessed March 23, 2016) was created in 1985 to provide technical expertise to
permitting authorities to ensure that new processes employed for sewage sludge treatment effectively
reduce pathogens. The PEC reviews and makes recommendations on new applications proposing new,
innovative, or alternative sewage sludge pathogen reduction processes that are the equivalent of those
processes listed in 40 CFR Part 503 Sewage Sludge Standards.
2.1.2 Occupational Safety and Health Administration (OSHA)
OSHA's mission is to assure safe and healthful workplaces by setting and enforcing standards,
and by providing training, outreach, education and assistance. Employers, such as wastewater utilities,
must comply with all applicable OSHA standards. Employers must also comply with the General Duty
Clause of the OSH Act, which requires employers to keep their workplace free of serious recognized
hazards.
Since 2014, OSHA (https://www.osha.govA last accessed March 23, 2016) has been involved in
formation of a policy for the storage and treatment of contaminated waste through the White House
National Security Council (WHNSC) Sub-Interagency Policy Committee (Sub-IPC). Together, OSHA,
National Institutes of Health (NIH), Department of Health and Human Services (HHS), Department of
Homeland Security (DHS), and EPA are all contributing to the Sub-IPC's interagency effort. The Sub-
IPC met in November of 2014 to discuss collection, storage, treatment and disposal of Ebola-
contaminated waste. The Sub-IPC also hosted a workshop in April, 2015, for approximately 60 local,
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
3-3
-------
state, and federal agency personnel and representatives from the healthcare and waste management
industries, labor unions, and associations.
The Sub-IPC identified key challenges and action items:
~ Development of a national plan.
~ Development of a strategic communications plan.
~ Development of training/education materials.
~ Review of waste management and disposal plans.
~ Identification of additional research needs.
~ Development of federal reach-back capability to SMEs.
As its part of its role in the Sub-IPC, OSHA is interested in protecting solid waste and
wastewater workers from exposure to infectious agents, including B. anthracis. OSHA seeks the
regulatory and guidelines needs of wastewater and affiliated sectors, specifically with regard to the
introduction of Category A infectious agents, specifically Ebola, into medical waste streams. (Note that
anthrax spores are not listed as category A agents). OSHA is examining Category A infectious agents,
focused on solid waste (as opposed to liquid waste or wastewater). This work will also include
development of an external or public affairs guidelines and communications rollout plan for Sub-IPC
products.
2.1.3 Department of Homeland Security - Protective Security Advisors (PSA)
The Department of Homeland Security, National Protection and Programs Directorate,
Office of Infrastructure Protection operates the Protective Security Advisor Program
(http://www.dhs.eov/protective-seciiiity-advisors. last accessed March 23, 2016) composed of Regional
Directors and PSAs. PSAs facilitate local field activities in coordination with other Department of
Homeland Security offices. In some areas and activities/incidents, the PSAs were involved with
emergency management planning.
2.2 State/City/Region Experience, Lessons Learned, and Current Process
The workshop participants heard from representatives of local and regional entities about how
they had handled biocontamination incidents, including Ebola and anthrax. The local agencies offered
perspectives on topics ranging from testing and evaluation protocols, implementation and capabilities,
communication and outreach, and regulatory and research gaps.
2.2.1 Metropolitan Washington Council of Governments (MWCOG)
The Metropolitan Washington Council of Governments (http://www.mwcog.ore/. last accessed
March 23, 2016) provides a framework for regulatory issues in Maryland and Virginia and the District
of Columbia, including transportation, environment (including water quality issues), homeland security,
health and human services, public safety and more. MWCOG addresses broad themes and holistically
examines ways to develop recommendations for elected officials, managers, and the public. MWCOG
offered the local and operational perspective, noting that wastewater and drinking water infrastructure
cover a large area and are interconnected (not including wells and septic systems).
3-4
XW ERF
-------
2.2.2 New York City Department of Environmental Protection
New York City's Department of Environmental Protection (http://www.nyc. gov/dep/. last
accessed March 23, 2016) has experience related to two of the nation's most severe biocontamination
events: the 2001 anthrax release and the 2014 Ebola outbreak.
2.3 Utility and Other Stakeholder Perspectives
The next segment of the workshop focused on a variety of utility capabilities, including
determining what research to conduct and at what levels - bench, pilot, or full scale - to meet the
technical needs of the utilities. Such technical needs are related to a diverse set of topics, ranging from
onsite pretreatment of wastewater prior to discharge to the collection system, fate and transport of
pathogens in collection systems and treatment plants, and effluent reuse or disposal.
In considering these research questions, workshop participants examined five research operations
to illustrate their different capabilities (see Table 2-1) - accepting biocontaminated wastewater, testing
and evaluation, limits of implementation, and capabilities. Various viewpoints were presented, from
state/city and region experience, lessons learned, and current processes. (See Appendix B for a list of
participants.) The group also explored communication planning needs and identified regulatory and
research gaps. Participants explored the information needed for utilities to accept bio
contaminated materials, from the headwaters through the plant, as well as downstream users. Also, the
group considered how best to contain the biocontaminants so that they are isolated while in the plant and
do not affect sludge or secondary treatments, and most importantly, do not result in worker exposure.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
3-5
-------
Table 2-1. Five research operations illustrate different scales for wastewater research. Listed in order presented.
Test and Evaluation Facility (T&E, Cincinnati, OH)
RCRA-permitted TSDF, located adjacent to Greater Cincinnati WWTP
High-bay (33,000 sq. ft.) and five laboratories
Analytical instrumentation and machine shop
Pilot-Scale Activated Sludge Treatment Plant
Operation scales to full size plant
Flow Rate: 0.5 L/min
Primary Clarifier: 25 L (0.84 h residence time)
Aeration Basin: 213 L (7.09 h residence time)
Secondary Clarifier: 52 L (1.75 h res. time)
Previous experiments: fate of terpenes, aldicarb, silver nanoparticles
Infrastructure material test bed;
Six identical wastewater test beds designed to study pipe material
Plumbed to deliver 280 gpm (total) of non-chlorinated secondary effluent from Cincinnati MSDGC Mill Creek WWTP
Configured to monitor and record flow, pH and conductivity continuously
Soil Columns for Land Applied Sludge
For fate and transport of contaminants in the soil column below land applied sludge
One column is 30 ft tall, another is 10 ft
16 in diameter PVC pipe soil columns, pressurizable to 50 ft of water, with sampling ports along height
Previous experiments: aquifer recharge studies
Decontamination Loop
75- foot PVC pipe recirculation loop focused on drinking water research
Allows the injection of contaminants and decontaminants into the loop
Past contaminants include Bacillus globigii, strontium, cesium, cobalt
Outfitted with 30 removable coupons made of pipe material
Ductile iron, concrete (others possible)
Water quality measurements
pH, conductivity, temperature, free chlorine, and ORP
Biosafety Level 2 (BSL-2) laboratory
Example: Developed standard operating procedures to treat 8ac///us-contaminated wash water
Bacillus globigii used as a surrogate for live anthrax
Tested several wash water formulations, bleach concentrations, temperatures, pH
Air Force Institute of Technology (AFIT: Dayton, OH)
AFIT is committed to providing defense-focused graduate and professional continuing education and research to sustain the technological
supremacy of America's air and space forces.
Researching how activated sludge responds to and recovers from exposure to Bacillus surrogates and/or other organisms.
Utilize Sequencing Batch Reactors (SBRs)
Build on previous work regarding the effect of OP chemical warfare surrogates on activated sludge performance and community
structure.
Examine short and long term effects.
Use multiple Bacillus surrogates and/or other organisms at various concentrations.
Investigate correlation of bench scale SBR results with pilot scale experiments at T&E
Water Security Test Bed (Idaho Falls, ID)
Phase I of the test bed is a once-through system
About 445' of 8° cement mortar lined, ductile iron pipe (water main)
6x1° service connections/sample ports, two hydrants
15' pipe material coupon section for sampling the interior of the pipe surface
Above ground system, underlined by secondary containment
28,000 gallon lagoon which receives water from the pipe, thus supplying a source of contaminated water for pretreatment systems
Mobile capabilities
Mobile Waste Water Treatment
EPAAOP treatment trailer
On-site system for building wash, wash water containment, particle treatment, and water reuse.
Mobile Sample Collection/Concentration
Automated water pathogen sample concentrator
Enables collection of samples at contamination site - no transport of large volumes of potentially contaminated water and detection of
lower pathogen concentration
Currently for low turbidity water; enhancements planned
3-6
XW ERF
-------
CHAPTER 3.0
Needs and Requirements for
Accepting Biocontaminated Wastewater
After gathering the perspectives and experiences of the workshop participants when dealing with
biocontaminated wastewater on different scales, the group looked at what is needed for a facility to
accept biocontaminated materials.
3.1 Accurate and Available Science-Based Guidelines
Before utilities can accept biocontaminated wastewater, they should have consistent, science-
based guidelines about how the biocontaminant can be deactivated/pretreated to avoid affecting the
conveyance system, treatment plant, and public and environmental health. Participants suggested that
one central agency should issue the guidelines for accepting biocontaminated wastewater. The
guidelines should provide a clear plan of action to assess and evaluate the risk to the plant, its workers,
and the general public.
For chemical, biological, and radiological contaminant incidents, EPA provides guidance on
decontamination for drinking water and wastewater utilities. This guidance, not focused on a specific
contamination, covers topics including handling of contaminated water, decontamination guidance, and
decontamination-specific training, (https://www.epa.gov/waterutilityresponse/learn-about-
decontamination-drinking-water-and-wastewater-utilities. last accessed March 23, 2016).
During the discussion, it was evident that there are many lessons learned during the Ebola
outbreak that can be transferred to future incidents. For example, extensive guidance was issued after the
first set of Ebola patients arrived in the United States. The Centers for Disease Control and Prevention
(CDC) had originally released interim guidance that said it was acceptable to flush waste into the sewer
without any pretreatment. Standard Operating Procedures (SOPs) were later released by the U.S. Army
Institute of Public Health at the Aberdeen Proving Ground on October 22, 2014 and are available at
http://www.casaweb.org/documemits/evdwastemamageroentonmtfsop.pdf. last accessed March 23, 2016.
The SOP calls for pretreatment of wastewater prior to discharge to the sewer system.
In November of 2014, the CDC issued "Interim Guidance for Managers and Workers Handling
Untreated Sewage from Individuals with Ebola in the United States"
(http://www.cdc.gov/vhf/ebola/prevetittoti/handlitig-sewage.html last accessed March 23, 2016), a health
and safety plan for sewage, chemicals, and biosolids at all locations. The interim guidance still
recommended discharging without pretreatment and instead suggested that workers protect themselves
from exposure to infectious agents including Ebola virus when working with untreated sewage from
hospitals, medical facilities, and other facilities, through the use of personal protective equipment (PPE)
and basic hygiene practices. The Water Research Foundation (WRF) also released a statement that
Ebola had not survived outside of a host for more than minutes (10/15/2014), although further literature
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
3-7
-------
review suggested longer persistence in certain aqueous media. Participants noted the difficulties with the
inconsistent messages and the science on which they were based, or the lack thereof.
Further, the National Response Team's 2005 draft guidance "Appendix E: Guidelines for
discharging anthrax decontamination wastewater to POTWs" contains information and guidelines for
handling, treatment (disinfection), and disposal of wastewater generated during the decontamination of
buildings or similar property and for "contained" and "stored" decontamination wastewater. The
relationship between the anthrax decontamination wastewater and wastewater entering the collection
system is unclear.
3.2 Coordination between Agencies
The participants suggest gathering federal and state agencies to ensure that they understand the
challenges faced by local utilities. The agencies could then offer guidelines on actions for various
situations, which could avoid conflicting guidelines. For
instance, one utility was reported by participants to have
received conflicting information while consulting with
different agencies (CDC, EPA, other utilities) as to
whether to add chlorine into the system during the Ebola
outbreak
There was great interest in a "national central
laboratory" to provide technical and analytical support.
EPA's Water Laboratory Alliance
(https://www.epa.eov/waterlabnetwork. last accessed
March 23, 2016) was briefly discussed. EPA's Water
Alliance was charged with wastewater analysis but had
limited capability to handle Select Agents like
aerosolizable Bacillus anthracis. CDC had more capacity
but was focused primarily on clinical, not environmental,
samples. At the state and local level, an interagency task
force coordinated with state public health officials and
local public health agencies to develop local guidelines on
analytical issues was suggested.
The workshop participants suggested coordination
among agencies to develop uniform and unified guidelines
for utility response plans, based on state of the science
assessment for utility response. These suggestions and
guidelines should be provided by an interagency,
interdisciplinary workgroup (including industry and
government experts, EPA, Centers for Disease Control
and Prevention (CDC)/National Institute for Occupational
Safety and Health (NIOSH), OSHA, and others).Further,
development of these guidelines should be a funded effort.
The resulting guidelines should recognize that different
agencies have different responsibilities relevant to the response. For instance, CDC may have public
Ebola in New York City (2014)
New York's part in the 2014 Ebola outbreak
started on October 23, 2014, when physician
Craig Spencer was diagnosed. Dr. Spencer had
just returned from working with Doctors Without
Borders in Guinea, a country in west Africa. He
was hospitalized at Bellevue Hospital.
The patient's waste was treated in accordance
with Bellevue procedures, but there was
additional cleanup afterward. The Department of
Environmental Protection's (DEP's) Office of
Environmental Health and Safety contacted the
New York City Department of Health and Mental
Hygiene and the Centers for Disease Control
and Prevention for guidance to manage potential
waste disposal into the sewer system that may
have been contaminated by Ebola.
The Department of Environmental Protection
(DEP) and Bellevue Hospital identified the waste
line that the Ebola patient would use when
recovering. DEP initiated an around-the-clock
sodium hypochlorite disinfection operation using
hypo totes and a 5 mg/L dosage rate until the
patient was declared Ebola free.
CDC then gave guidance for workers and
managers for handling of waste and hygiene.
Workers were provided with three lockers for the
storage and disposal of uniforms and foul
weather gear. Washers and dryers were
installed at all locations with a high temperature
wash cycle to deal with Ebola.
All mid-level managers explained the guidance
to employees. Since there are many West
African travelers, there were concerns with
workers/staff.
3-8
XW ERF
-------
health responsibilities, OSHA/NIOSH may have worker safety responsibilities, and EPA may have
responsibility for cleanup and waste transport and disposal. The suggested guidelines should also take
into account the impact of the incident on utilities both in terms of regulatory compliance (for a utility in
compliance prior to the incident) and also in terms of disruption to the treatment process should the
incident occur unexpectedly despite following the utility response plan for handing these wastes. The
suggested guidelines should also clarify the role of various federal regulations (and accompanying
enforcement actions) and interagency plans relative to such an incident, including: Comprehensive
Environmental Response, Compensation, and Liability Act of 1980 (CERCLA), Clean Water Act
(CWA), Safe Drinking Water Act (SDWA), National Contingency Plan, and others.
3.3 Readiness and Notification Protocols
Readiness is a major challenge faced by local utilities in the face of biocontamination.
Information prepared and shared before the contamination event will lead to better outcomes.
One utility representative noted that after experiencing a variety of events, the lessons learned
and the gaps in knowledge are similar, regardless of type of utility and contaminant involved (e.g.,
anthrax, Ebola, petroleum spill), although utilities will have approaches specific to their system. For
example, a major challenge with the 2001 anthrax incident was that the urban sites were located in the
same drainage area. There were no definite suggestions, so the decision was made to pre-chlorinate at
one location (due to the shared drainage area). Regardless of this specific location, the effectiveness of
such pre-chlorination was unknown.
Workshop participants discussed that notification of the presence of a biocontaminant should be
immediate, and hopefully in advance of the contaminated water entering the system. It should be clear
whether the material is infectious or not, and whether the contaminated water can be disinfected before
acceptance.
Acceptance procedures should consider containment at point of entry, if possible. It is much
easier to control and minimize widespread exposure if contamination is contained prior to release to a
sanitary sewer system. Effectiveness of traditional treatment was discussed, but other technologies might
be more effective in eradicating pathogens.
Some discussion involved potential support by military assets, perhaps related to military
defensive preparedness for biological attacks. No representatives from military organizations involved in
such preparedness activities (e.g., Civil Support Teams, Service Laboratories, and others) were present
during this workshop to clarify their roles, responsibilities, and capabilities. However, these military
organizations should be involved in development of the suggested uniform/unified guidelines suggested
in Section 3.2.
3.4 Response Timeline
The response timeline (technical vs. regulatory) affects operational decision making from a
utility standpoint. Special consideration was given to identifying the point of contact at the federal level.
For example, during the Ebola outbreak, there was no central place to call in the District of Columbia.
The DC utility is regulated directly by EPA, but because the EPA office that was contacted keeps
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
3-9
-------
regular office hours, it was difficult to obtain proper information late on a Friday afternoon. Once the
point of contact had been notified of the issue and challenges, there was no clear next step for the utility.
The participants noted that timeline challenges are very real for utilities. The functional time
horizon is not enough to make real life decisions. No two incidents are the same, and response
capabilities are different in individual facilities. In a response environment, primary involvement is
important and meaningful. Although the research community is supportive, they generally weigh in after
an approximately two-week lag time.
3.5 Characterization of the Biocontaminant(s)
Before acceptance of a biocontaminant, a facility needs an accurate profile, including general
type of material, flow, characteristics, etc. Generally, there are three main types of potential
biocontaminated materials:
1. Species intentionally released as biological weapons (such as Bacillus anthracis)
2. Biohazardous waste or infectious waste is waste contaminated with potentially infectious agents or
other materials that are deemed a threat to public health or the environment.
3. Medical waste is all waste materials generated at health care facilities such as hospitals, clinics,
physicians' offices, dental practices, blood banks, and veterinary hospitals, as well as medical
research facilities and laboratories. This category also includes biological waste and discarded
materials contaminated with blood, excretion, exudates, or secretion from human beings or animals
that are isolated to protect others from communicable diseases.
It is important to know the exposure pathways, from entry into the collection system (e.g., "toilet
flush") until reentry of the water into the environment. The participants expressed a need to know the
concentrations that could be re-released into air that could be inhaled by plant workers or the general
public.
Utilities need information about whether the biocontaminant can be disinfected before
acceptance, and if the material can be contained and/or added to the system at a chosen point, so as not
to get into the collection systems. In addition, it is important to know the survival/persistence of the
contaminant(s).
3.6 Administrative and Financial Issues for Utilities
The workshop group discussed that WRRFs need clear regulatory guidelines, pre-approved
agreement from the facility head, and legal advice for protections for all involved relevant to the
situation at hand. Pre-crisis legal agreements (including Mutual Aid agreements and pretreatment
ordinances and regulations) set the stage for quick, coordinated response. Pretreatment agreements,
which may be related to legal protections, should be specific about what can enter the system. In
addition, clear and consistent messaging should be easily understood and targeted to specific audiences.
OSHA does inspect WWTP operators and enforces OSHA standards according to the agency's
jurisdiction. A rough review of publicly available 2005-2014 data for WWTPs (North American
Industry Classification System (NAICS) 221310) shows approximately 375 violations of PPE standards
and more than 600 violations of the Respiratory Protection standard during non-emergency operations.
These numbers are variable depending on how the data are scoped (e.g., by different industry codes that
3-10
XW ERF
-------
could be applied to various WWTPs and related operations). During emergencies, OSHA typically
utilizes a two-phased approach to violations: 1) offer technical assistance, that is, non-enforcement
investigative approach working with federal, state, local, and private-sector partners to protect workers,
and 2) normal enforcement.
Facilities seeking liability protection under their permits need guidelines on appropriate limits for
disinfection and other parameters. For example, in the draft 2005 National Response Team guidance,
use of "Discharge Authorization Letter/Discharge Permits" is suggested:
"Once the decontamination wastewater has been successfully disinfected and the relevant parameters are
within the appropriate limits, the Incident Commander should formally request (in writing) approval for
discharge of the decontamination wastewater.. EPA strongly recommends that wastewater authorities
establish a formal (written) agreement that stipulates the conditions of the authority's approval of the
discharge...."
The workgroup discussed that the utility's management should exhibit a level of financial and
administrative support for exploring new testing and monitoring tools. If the utility did have anthrax or
other pathogens, would management encourage setting up a laboratory, in terms of providing financial
and administrative support, to include support in meeting any legal requirements for such a laboratory?
Also, several of the participants conceded that most other utilities do not have resources or inclination to
do this type of exercise. Smaller utilities will pass it up the line to the larger utilities.
Participants expressed significant concern with cleanup and disposal costs associated with
contaminated materials and the long-term impacts to biological systems and assets. Testing is needed to
ensure that the facility, the receiving waters, and biosolids get "back-to-normal." Additional expenses
can be incurred for unanticipated testing
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
3-11
-------
-------
CHAPTER 4.0
Tests, Protocols, and Guidelines
for Accepting Waste
All participants suggested the need for one set of guidelines and suggested that it is developed at
a federal level. This will help ensure that all parties involved have a shared understanding of the test
protocols and guidelines, thereby potentially minimizing or eliminating impacts on the WWTP and its
workers.
Interagency workgroups (including industry and government experts, EPA, CDC/NIOSH,
OSHA, and others) should holistically evaluate a suite of potential compounds and high-consequence
pathogens that may be present in the effluent from treated wastewater. Sampling and analysis protocols
for priority agents should be available for WWTP laboratories to access during incidents.
Workgroups may develop guidelines on the level or type of pretreatment or other treatment
control, as appropriate. There was interest in a National Central Laboratory to provide technical and
analytical support, similar to the Interagency Steering Committee on Radiation Standards (ISCORS)
model. Such a laboratory would include DHS, CDC, EPA, Department of Defense, expert
microbiologists, wastewater treatment experts, and OSHA. EPA's Water Laboratory Alliance, which
also includes wastewater in its mission space, was discussed, although high-consequence pathogens are
associated with a number of legal requirements that preclude most laboratories from analyzing for these
pathogens.
Also of interest was a gap analysis of what research has been conducted that addresses the
missing data or perceived gaps. For example, the group emphasized the need to define the fate and
treatment of anthrax through a treatment system, including the ability of the organism to replicate. Gap
analysis of the following questions may be useful:
~ What happens in an aeration basin?
~ Does the anthrax pass through to the receiving stream?
~ What is the best way to handle solids from treatment plants, e.g., incineration, land application
and/or subsidiary operations like the struvite recovery process (see WERF Report INFR4SG09b,
http://www.weif. org/)?
~ What is the efficiency of standard wastewater treatment disinfection and other treatment options?
~ What are the effects of decontaminants on the WWTP operations?
Not all disinfection techniques (chlorination, UV, etc.) have equivalent removal efficacy. The
group considered portable treatment units such as membrane filters available for use at the wastewater
facility in the affected service area (although this approach is probably not feasible for the largest
facilities).
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
4-1
-------
4.1 Tests and Protocols
The participants mentioned that analysis/sampling protocols should have clear Quality
Assurance/Quality Control (QA/QC) and sufficient sensitivity and specificity to assess and detect
contaminants. The suggested guidelines should include practical analytical methods for quantification
and clear guidelines for responsibilities and liabilities.
Many jurisdictions have general prohibitions on discharges of toxic substances without prior
permission, based on interpretation of the underlying statutes. For example, some requests have had to
be accompanied by event-specific data, samples, and a decontamination plan. During the Ebola
outbreak, several state agencies in the Western United States contacted local health departments to
coordinate information and healthcare facilities to establish lines of communication. The agencies
followed CDC's recommended protocol. No patients with the Ebola virus were treated in the area, so the
greater lessons learned were about issues surrounding coordinating information.
4.2 Monitoring and Analysis
In addition to research for monitoring and analysis, there might be implementation of a "Red Bag
Solution," that is, a tracking system for pathogens and biohazardous waste in real time. Monitoring air
quality for spores and other contaminants may also be important. There is a need for a plan that
incorporates the lag time between air monitoring for spores and processing what is already present in
wastewater. Also, an early detection and warning system, currently developed for drinking water
systems, may be useful for wastewater systems. (https://www.epa.gov/waterqualitvsurvetHance last
accessed March 24, 2016)
The group discussed the critical nature of the ability to match pathogens to operations parameters
such as influent fluctuations. For example, one county utility system uses next generation sequencing, a
groundwater replenishing system (GWRS), fecal indicator bacteria (FIB), and Escherichia coli
monitoring. The whole virus sequence can be matched to a library, which offers a more comprehensive
characterization and fate and transport information for known and unknown contaminants and provides
advance detection. The GWRS could possibly be utilized to trace pathogens back to a source if there
were a monitoring tool that, for example, could notice a change in the pattern of the pathogens being
monitored.
4-2
XWERF
-------
Many of the participants commented that the methods
available are not easy to use. Also, as soon as the utility
identifies a pathogen, there is substantially more work to be
done. Always test with a culture base to confirm, suggested
one of the participants. If it is an agent the utility cannot
handle, the test can be sent to another laboratory.
Monitoring systems collect data on the types of
organisms and temperature changes, as well as other
important information. A good system can detect an outbreak
in a specific pathogen, including background contamination
from spores. Background contamination includes runoff from
washing of animal hides in meat processing facilities, runoff
at carwashes, and similar sources.
Issues with emerging viruses and pathogens were also
noted. As more WRRFs are required to remove nutrients,
various biological nutrient removal processes are being
implemented, and the microbial community in the system has
changed. However, removal of biological nutrients does not
mean greater removal of these microbial communities; rather,
it means greater concentrations of these microbes.
Participants spoke about transport studies showing that urine is still a viable medium for viruses.
Urine is not sterile: 70% of restrooms contain viruses (Verani et al., 2014), some of which are thought to
arise from urine because viruses may not be efficiently filtered by the kidneys. Using disinfectants still
leaves some contamination - dispersion via aerosolization is also a factor (Sinclair et al., 2008).
Researchers mentioned that reoviruses are the most common viruses in wastewater (Sedmak et
al., 2005). The viruses clump and are more resistant to chlorine than other respiratory viruses. Because
of these and other properties of reoviruses, some participants noted that viruses can be found infectious
even 10 days after release via waste water-related exposure routes.
The group noted that there are many tools at hand, including multiple polymerase chain reaction
(PCR) technologies - digital and quantitative PCR synthetic reference materials, fate and transport
studies, reduction studies, and more. The concern is that there is a need for unified federal suggestions
on what to prepare for, along with suggested laboratory guidelines. For instance, the participants
suggested a need for guidelines and recommendations on topics such as a priority list of pathogens and
assays on hand, CDC's 65 Select Agents and Toxins, the latest PCR assays, reference materials, etc.
4.3 Existing Guidelines and Guidance
Participants discussed that guidelines should address whether the event (and the pathogen) is
known or unknown. The suggested guidelines should also show how to handle the pretreated
biocontaminated waste. The group discussed a few of the existing guidelines. That discussion is
summarized below.
WHAT QUALIFIES ASA
BIOHAZARD?
Biohazard is defined as:
~ Hazardous biological materials such as
infectious agents (substances from or of
biological origin) and substances actually
or potentially contaminated with them.
~ Human blood, human blood components,
and products made from human blood;
potentially infectious body fluids and
materials including: semen, vaginal
secretions, cerebrospinal fluid, synovial
fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in
dental situations, any bodily fluid with
visible blood, and all bodily fluids where it
is difficult or impossible to differentiate
between bodily fluids; any unfixed tissue or
organ (other than intact skin) from a
human (living or dead); and human
sourced cell or tissue cultures, organ
cultures, culture medium or other
solutions; and blood, organs, or other
tissues from experimental animals infected
with human pathogens.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
4-3
-------
4.3.1 Medical Waste Disposal Guidelines
Medical waste disposal is regulated primarily at the state level. "Model Guidelines for State
Medical Waste Management" (https://www3.epa.gov/epawaste/nonhaz/industrial/medicalA last accessed
March 24, 2016) is the product of a cooperative agreement between the Council of State Governments
and EPA. The Medical Waste Tracking Act of 1988 requires the EPA to identify alternative (i.e., non-
regulatory) approaches to medical waste management. The current guidelines are in response to this
requirement. There is no category for bioinfectious organisms under that program.
4.3.2 Biohazardous Spill Cleanup Guidelines
The National Institutes of Health (NIH) has issued Biohazardous Spill Clean-up Guidelines
(http://www.ors.od.nih.eov/sr/dohs/BioSafetv/Paees/bio chem safety.aspx. last accessed March 23,
2016) as a part of its Biological Safety Program. Biohazardous material is regulated at the state level.
Medical waste disposal and waste management practices are not consistent from state to state. Individual
facilities can impose standards to protect their system.
4.3.3 WERF Guidance Document
WERF Report 04CTS9Sa (http://www.werf.ore) provides Early Warning System (EWS)
guidance to wastewater utilities and describes the steps they should take to set up an EWS, including
assessment criteria, sample preparation, databases of chemical, biological, and radiological (CBR)
monitoring and communications systems, sensors, upset modalities, anomaly detection and data mining.
4.3.4 Quality Assurance Project Plan - Pathogen Equivalency Committee (PEC)
Demonstrating the effectiveness of innovative and/or alternative sewage sludge disinfection
processes for the purposes of receiving a recommendation of equivalency to a process that significantly
or further reduces pathogens involves a quality assurance project plan (QAPP). The PEC QAPP process
is complicated, with much back and forth between the PEC and the applicant to make sure the standards
are met. The equivalency process provides QAPP objectives, including adherence to four criteria:
1) Identify critical process parameters such as treatment time, temperature, pH, % total solids range, and
chemical dosing.
2) Next, verify reduction in levels of pathogens.
3) The project is then scaled up to a demonstration phase.
4) Finally, the QAPP is submitted to the PEC with appropriate documentation.
Development and adherence to the QAPP helps prevent technical problems, although technical
problems may happen even in the best-planned operations. If the QAPP is not followed or is not
complete, then financial problems may arise. After the criteria are met and the QAPP is submitted, the
PEC communicates with the Office of Science and Technology and offers an opinion on process.
Equivalency is awarded or not based on PEC recommendations.
Recently, PEC weighed in on many questions during the Ebola outbreak, particularly in the fall
of 2014. For example, the PEC was contacted in 2014 by a citizen near Emory University in Atlanta,
Georgia (which had accepted an Ebola patient). The PEC relied on experts within the committee to
come up with guidelines.
4-4
XWERF
-------
4.4 Interconnectivity
The workshop participants emphasized the importance of having a robust system to deal with
interconnections among all involved agencies through the use of deliberate response and management
protocols. As an example, the Washington, D.C.,
metropolitan area has had many different contamination
experiences, including region-wide events such as 9/11
and mass transit system accidents; water quality/quantity
issues such as pipe breaks, sewage and contamination
spills; natural events such as storms, algal blooms and
drought; and medical situations such as anthrax and Ebola.
All of these incidents were different, yet many facets of
the response had similar components.
In all situations, participants discussed that it is
most important to have existing working relationships. In a
crisis, trust is essential. There should be clear lines of
authority at all levels (local, state, regional, federal, tribal,
international) and across sectors. Coordination and
protocols are critical, as are preparation and pre-event
simulations and exercises. Access to information from
subject matter experts (including those who are not in
agreement with mainstream ideas) is necessary to get the
full view of the situation. More informally, existing
relationships make it easier to access resources ("who
knows what?") and track similar experiences in other places. The group advised that it is not ideal to
wait until something happens to try to start building relationships.
4.5 Jurisdiction
The group discussed the high level of interconnection between and within wastewater and
stormwater systems. Because they operate a combined system, many of the WRRFs have combined
exposures. The footprint of the WRRF collection system does not necessary abide by political
jurisdictional boundaries.
Regarding drinking water supply, there are potential contamination issues upstream of facilities.
Participants were concerned about upstream/downstream and where the watersheds (including the sewer
outfalls) are, which contributes to the complexity of physical and infrastructure models. Participants
expressed a need to have Mutual Aid agreements in place to enable emergency response.
The participants also stressed that the permitting authority needs to be flexible regarding
biocontaminant issues, and all parties involved need to work together to determine what is needed to
provide the most protection to public health. The participants suggested that a POTW Guidelines
Document is needed that outlines procedures to address events that may occur in the collection system
or treatment plant. The group discussed consideration of events in which the cause of the
biocontamination event is known and those events where the cause is unknown or unintentional.
SNAPSHOT -WASHINGTON, DC
Jurisdictional issues and Regulatory
Authority
Regulatory authority abides in multiple entities in the
Washington metropolitan area: EPA Region 3,
District Department of Energy and the Environment,
Maryland Department of the Environment, and
Virginia Department of Environmental Quality.
Responsibility often overlaps as well: drinking water,
local governments, authorities and private firms;
wastewater, local governments and authorities such
as the Washington Suburban Sanitary Commission;
stormwater, local governments. Occasionally water
is private.
The entity in charge affects regulatory frameworks,
decision-making, and the notion that their clients
(whoever they are) are also part of that scenario.
EPA's Chesapeake Bay program adds another layer
of responsibility onto local governments.
Regulatory authority exists to protect the plant and
the environment, and fines can be levied if plants
are not in compliance.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
4-5
-------
An example was offered where a national-level disaster is transferred to a single utility. In this
type of case, there is criminal liability for spreading biocontamination in a community, or, at the very
least, permit violations. In this example, the utility did not act on anthrax because, under the terms of the
union contract, OSHA could cite the utility as an "unsafe workplace." Also, its workforce could have
been eligible for paid leave if anthrax or a biocontaminant were introduced.
4.6 Regulatory Framework
As new processes are developed to treat sewage sludge, it is important to consider the differences
between Class A and Class B biosolids and how those differences affect any guidelines suggested by
this workshop. For example, there are no site restrictions with Class A biosolids, but Class B biosolids
have restrictions that need to be adhered to. There was discussion about pathogen reduction in a biosolid
after it has been conditioned, and the potential for a utility to monetize and market the product that can
accomplish the reduction. Comments were made by a number of participants that Class A may be
appropriate for land application for crops.
Applicable regulations differ markedly across the United States, even in the same general region,
along with the terms potentially used to describe wastewater contaminated with high consequence
pathogens. For example, for a utility in the Midwest, its local "Sewage and Waste Control Ordinance"
effectively eliminates offensive or dangerous discharges into the public sewer system and sets specific
limits on the quantity and quality of wastes that can be discharged by industrial users. Section 2 of the
ordinance outlines discharge prohibitions such as "substances sufficient to create a public nuisance or
hazard to life, to cause injury or acute worker health or safety problems...." and "Water or wastes
containing toxic substances in quantities which are sufficient to interfere with the biological processes of
the water reclamation facilities"
(https://www.mwrd.Org/irj/go/km/docs/documents/MWRD/internet/Departments/MR/docs/ordinances/S
ewage and Waste Control Ordinance.pdf. last accessed March 24, 2016).
In a different Midwestern state, potentially infectious medical waste (PIMW) discharge is
prohibited unless the utility complies with its state's administrative code (Sewage and Waste Control
Ordinance As Amended April 9, 2015), which prohibits pretreatment of any industrial wastes
detrimental to the wastewater treatment works or its proper and efficient operation and maintenance.
There are no PIMW facilities in that utility's service area. In addition, untreated medical waste is banned
from all of that state's landfills.
After further discussion, the group revisited the Category A list (http://www.phmsa.dot.gov/ last
accessed March 24, 2016). Participants noted that the Category A list was relevant to transporting waste,
not a large-scale cleanup. Siloed programs and universal procedures were also discussed, as well as
individual pathogens (i.e., responding to new information where there is no historical information).
4.7 Permitting Authorities
Participants suggested that the federal government should lead in providing guidelines and
direction on acceptance of biocontaminated wastewater, its treatment, and worker and plant safety. They
explained that such guidelines should address best efforts to comply with these developed "protocols and
guidelines" in the event that non-compliance with the Clean Water Act results from accepting and treating
the biocontaminated wastewater. The group suggested the potential need for a process to temporarily
4-6
XWERF
-------
suspend permit limits during uncontrolled release scenarios and guidelines for a formal request from a
generator or hauler for discharge.
There was general agreement that there should be provisions for third-party lawsuits and
enforcement actions and also for the declaration of an emergency. The participants also suggested there
should be guidelines for matching federal relief efforts with appropriate avenues for relief from state and
local regulation and enforcement penalties.
4.8 Design and Implementation
The workshop participants engaged in a general discussion of whether existing plant emergency
response plans could be adapted or expanded for biocontaminated water, and if so, what other
information would be needed. Participants suggested that Water Laboratory Alliance (WLA) coverage
could be expanded to encourage development of more WRRF laboratories.
The group discussed collaboration of local and federal agencies with WRRFs with training and
exercises to test plans and protocols, but most stated that the design and evaluation of the plans should
come from a federal agency (or a combination of agencies) such as EPA, NHSRC, CDC, or OSHA.
There was also support for creation and funding of an interagency group composed of the agencies, with
representatives from utilities and scientists, engineers, and other stakeholders such as sector
associations.
The participants believed it would be useful to classify biocontaminated materials into groups
according to physical, chemical and biochemical properties, and then develop tests for each major
group. Representative samples, method detection limits, and certification, parallel independent split
samples, and real time monitoring were also mentioned as design and implementation components.
Financial and technical constraints to be overcome include, but are not limited to, personnel
costs, testing at various scales, and more. Testing using surrogates such as Clostridium difficile or C.
perfringens might be effective during and after cleanup of an event.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
4-7
-------
-------
CHAPTER 5.0
Safety and Health Concerns
Wastewater contains organisms that can affect the health of workers, including a variety of
organisms capable of causing human disease such as:
~ Bacteria (Salmonellae spp., Shigellae spp., V. cholerae, E. coli, B. anthracis, Y. pestis).
~ Viruses (Enteroviruses, rotaviruses, Hepatitis, Coxsackie viruses, Adenoviruses).
~ Protozoa (Giardia lamblia, Entamoeba histolytica, Acanthamoeba).
Organisms that require a host in which to reproduce are not going to be able to reproduce in the
wastewater collection and treatment system, stated one participant [unless the host is somehow present
in the system]. The number of such organisms may decrease - both due to inactivation and dilution - or
remain constant during passage down the pipe to the treatment plant, but will not increase. This is not
true for organisms that reproduce independent of a host.
5.1 Exposure - Workers
Due to the importance of the topic of worker exposure to high consequence pathogens, a separate
but related workshop is planned for mid-2016. The workshop participants were informed about this, so
important issues regarding worker exposure were introduced but not extensively developed or discussed.
Following is some relevant summary, and the reader is encouraged to refer to the report from the future
workshop.
Workers can be exposed to biocontaminants by a variety of routes, for example, direct contact
and aerosolization. Control of such exposures is summarized in Figure 5-1. Exposure to biological
contaminants may also come from solid waste in wastewater. Some solids are separated as debris at
some point in the wastewater treatment process and may contain higher concentrations of pathogens
than are found in (diluted) wastewater. Also, solids may contain needles and other sharp objects. There
is anecdotal evidence of workers' exposure to solids and wastewater that suggests more research is
needed (i.e., 1990 worker testimony about contracting hepatitis B while screening debris from
waste water/raw sewage).
For comparative purposes, workshop participants discussed the presence of Ebola and how
utility workers and unions might be handling potentially contaminated water. Unions should work with
the WWTPs to accept the risk involved and establish levels of protection.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
5-1
-------
Ellmnates the e*pc6*-re
before it can occur
Requires a physical change
to the woikp^ace
Administrative &
Work Practict Controls
Personal Protective Equipment
(including respirators)
Requires worker or employer
to DO something
Requires vvorVer
to WEAR something
Figure 5-1. Controlling Worker Exposures in Wastewater Operations,
A hierarchy of controls can help reduce or eliminate worker exposures to microbes and other hazards in wastewater.
Graphic courtesy ofOSHA.
Wastewater operations may involve a variety of hazards, including exposure to microbes,
chemicals, and radiation. Workers may be exposed during various operations, including in and around
WWTPs when conducting maintenance on wastewater conduits (pipes and other parts of the collection
system) and infrastructure.
The primary route of exposure for workers may be inhalation of infectious materials. Inhalation
exposure may come from droplets and aerosolized particles of a variety of sizes due to certain work and
mechanical processes. Small droplets (conventionally <5 urn) can evaporate to form airborne droplet
nuclei that can be inhaled. Larger droplets (conventionally >5 jam) also can deposit in a variety of
locations along the worker's respiratory tract or can make contact with unprotected mucous membranes
(eyes, nose, mouth) or broken skin. Particles in a range of sizes can travel a variety of distances from
their source, potentially resulting in worker exposure.
The group discussed variation of exposures by worksite and operation. Employers should assess
exposure hazards in the workplace by evaluating the hazards and then directly sampling the wastewater.
It is also important to sample the air in work and breathing zones. Work surfaces should also be
sampled. Worker exposure can be gauged via biomarkers such as blood, urine, etc.
Four scenarios of exposure to biological agents in wastewater treatment were considered:
1. Wastewater exposure and health in different occupational groups (Hansen et al., 2003). This
Copenhagen-based cohort study compared the morbidity and mortality in wastewater workers to that
of water supply workers. Results showed significant excess mortality among wastewater workers
and significant increased risk of primary liver cancer. Because the wastewater was itself an
exposure, it was difficult to determine the actual etiologic agent (e.g., role of potential exposure to
viruses in cancer development, impact of potential biological agent exposure on overall immune
function, identify and carcinogenicity of potential chemical exposure, etc.).
2. Work-related health effects among wastewater treatment plant workers (Albatanony and El-Shafie,
2011). This Egyptian cohort study compared wastewater workers versus non-exposed government
5-2
WWERF
-------
workers, and showed a significant increase in body aches, abdominal pain, breathing difficulties, and
other symptoms in exposed workers. Exposed workers also had a significantly higher incidence of
positive antibody tests for Hepatitis A and Hepatitis E and stool PCR for bacterial species (e.g., L.
spirochete).
3. Health risks of human exposure to wastewater. (EPA, 1981) This older study of American WWTP
workers showed that newer and less experienced workers had more gastrointestinal illness than
workers with more experience (and more exposure). The study data show no significant risks due to
the presence of viruses and bacteria in wastewater. (There are also anecdotal reports among workers
that being sick during the first few weeks/months of WWTP work is standard.)
4. Hepatitis E, Helicobacter pylori, and gastrointestinal symptoms in workers exposed to wastewater
(Jeggli et al., 2004). The cohort study compared sewage workers with other unexposed municipal
workers (e.g., laborers) and found no significant difference in development of peptic ulcer disease or
Hepatitis E between the groups. The study had an abundance of factors that may have confounded
analysis.
Participants discussed how a hierarchy of controls can help reduce or eliminate worker exposure
to microbes and other hazards in wastewater.
~ Engineering controls might include physical barriers that enclose workers and protect workers from
an enclosed process. Ventilation, including local exhaust ventilation or mechanical ventilation,
protects workers from the flow of aerosols in their direction.
~ Administrative controls and safer work practices might include creating areas where only a limited
number of workers can enter to reduce the overall number of exposed workers, providing facilities
for workers to wash up and/or shower and avoiding work tasks that contribute to the generation of
bioaerosols or droplet sprays. The group stressed that workers should follow established, vetted
protocols for routine wastewater operations, as well as for work during times of disease outbreaks,
known contamination events, or other emergency scenarios.
The group discussed use of PPE when engineering and administrative controls and work
practices do not control hazards sufficiently. PPE may include protection for eyes and face, hands and
skin, as well as respiratory protection. Employers should identify hazards and provide PPE appropriate
to prevent or reduce the hazard.
5.2 Training
The discussion about worker safety led to the general conclusion that training was a key factor in
maintaining a safe and healthy work environment during contamination incidents. Training in use of
PPE, hazardous materials, and incident scenarios were prioritized.
5.2.1 PPE Training
Workshop participants asserted that all workers should be trained on the hazards of their jobs and
know how to perform their jobs safely and how to protect themselves using employer-supplied controls.
Also, all workers should be aware of symptoms associated with infection with known or anticipated
biological contaminants and know how to report symptoms or other safety concerns.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
5-3
-------
The importance of developing approaches that were broadly applicable to many types of
biological contaminants was discussed, with specific approaches and protocols having been developed
for specific contaminants like Bacillus anthracis and the Ebola virus.
Equally important was the ability to identify groups of hazards (e.g., biological agents) that have
similar routes of transmission, infection pathways, and other characteristics, and the ability to implement
controls suitable for the pathogens in these groups.
5.2.2 Hazardous Materials Training
Utility representatives noted that, in most cases, proper training in handling hazardous materials
is limited to three to five people per facility. If circumstances arise where a screen cleaning of a
contaminated facility is needed, the utility will need personnel trained in hazardous material incidents
(e.g., benzene spill) to address biochemical and chemical concerns.
5.2.3 Incident Training
With safety considerations, scenario training is critical. The group discussed that most important
question of "Is it safe now?" Then, after an action has been taken, what is the safety factor, and what is
the evidence for that conclusion? For example, the group considered the training needed for a
catastrophic failure of Ebola-contaminated combined sewer overflow (CSO) into a public space.
Other questions arose during discussion, such as how to determine the personnel who would
receive that training. A participant noted that managers and workers feel terribly unprepared to respond
to biocontamination events. The group was in general agreement that "the worse it gets, the less
capability [the utilities] have to respond."
5.3 Transmission Risk
Discussion emphasized that wastewater inherently has risk from existing pathogens. Risk of
transmission may be no higher, so one function of a wastewater utility is to segregate the contaminated
material from the public rather than to impose more requirements on hospitals and others discharging to
a wastewater collection system. With regards to such discharges, different jurisdictions can have very
different agencies/parties that should be notified of a potential discharge. Participants explained that in
many cases there are no plans in place for waste disposal in hospitals, and the city has a "no discharge"
rule.
The participants discussed that there should be more steps for preventing worker illnesses via
monitoring. Medical monitoring should be available to workers with occupational exposure to
wastewater, and vaccinations provided to workers for pathogens of concern in wastewater and for other
disease agents (e.g., seasonal flu).
If the workplace creates a culture of safety and health that involves management and worker
input, workers are more likely to continue to come to work during disease outbreaks or other emergency
events. They need to be assured of the steps their employer is taking to protect them. Currently, there is
no specific infectious disease standard for employers, but existing OSHA standards could potentially
still protect wastewater workers from some, but not necessarily all, hazards. Even standards that do not
apply as legal requirements for certain types of exposure scenarios can still provide good frameworks
for how to implement controls and train workers.
5-4
XWERF
-------
CHAPTER 6.0
Communications
The group discussed how communications planning is important. Internal public information
officers and general managers both need to understand how to transmit the notion of risk to elected
officials and the general public. At some level, there is an overload, but sharing what is known and
unknown communicates trust. It also needs to be acknowledged that government sources are not always
trusted. Working to get community support may also involve sharing what is known and what is not
known.
Communications played a key role in an east coast environmental agency's handling of the
anthrax scare. The agency reached out to representatives from the six unions represented, as well as
EPA, local regulatory advisors, the mayor's office, and others to let them know about the problem, and
to give as much information as possible regarding plans of action.
During the Ebola outbreak, a southern California county reported pulling together a task force of
social services, housing, not just from the technical community, and not just about sewage/wastewater.
This is one way to get support, so fear (and the pathogen) doesn't spread through the community.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
6-1
-------
-------
CHAPTER 7.0
Data Gaps and Research Needs
To achieve the workshop goal of identifying data gaps and research needs, after discussing the
issues summarized above, workshop participants identified four key areas relevant to accepting bio-
contaminated wastewater:
~ Unified, sole-source guidelines based on sound science.
~ Characterization of biocontaminants.
~ Understanding and preventing worker exposure.
~ Management of post-treatment impacts.
Below is a discussion of each of these broad issues in more detail. The workshop participants
were not prescriptive for research plans, but provided important insight into the challenges underlying
each issue. They also provided questions that researchers should consider when planning activities to
address these gaps and needs. This non-prescriptive approach may prove beneficial to researchers
because of the multitudeand unforeseen natureof future biocontamination incidents. For example, a
new type of high consequence pathogen may emerge (such as genetically modified, antibiotic resistant
anthrax), or an unanticipated release scenario (for instance, involving multiple types of contaminants)
may result in unique decontamination needs. Regardless, if researchers keep in mind the questions
relevant to each of the broad categories, they might be able to plan research to address the most pressing
issues surrounding a specific biocontamination scenario.
7.1 The Need for Unified Guidelines
Participants explored the need for an environment where government agencies and utilities could
work together most efficiently, particularly when the greater good of the public (and not just technical
needs of the utilities) is impacted by biocontamination. The suggested, unified guidelines should apply
to federal agencies that deal with these issues.
Participants decided that the primary challenge is to develop a national plan (i.e., unified
guidelines) for safe handling and management of biocontaminated waste. Incident specific application
and implementation of the plan should be further supported through creation of a list of SMEs. This
plan would also apply to current and all future Category A infectious substances. Relatedly, specifically
for anthrax, anthrax spores should be added to Category A substances (in addition to anthrax cultures).
The plan should also include aspects of communication (e.g., external public affairs guidelines.) Also
suggested was the recognition of research gaps relevant to the plan, along with development of funding
sources for such research to meet these gaps.
The workshop participants suggested that the following questions be considered when
developing such unified guidelines:
~ How best can threats be identified and prioritized?
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
7-1
-------
~ How can credible risk data on transmission, survival, and dose-response be established quickly if an
event occurs?
~ How can misinformation/conflicting information be prevented?
~ How can utilities determine the best course of action?
~ Can utilities (cost effectively) prepare in advance of an event?
~ Can practical analytical methods that meet the listed criteria be developed in advance and/or easily
implemented in an event?
7.2 Characterization of Biocontaminants
Treatment facilities need real time data and reliable information before they can accept
biocontaminated wastewater. For example, factual data are needed on the fate, transport, and infection
rates of the pathogen. Once the pathogen is detected and treated, a monitoring protocol is needed.
The workshop participants suggested that the following questions be considered.
~ What is the fate (including replication) of potential pathogens in an aquatic system?
~ Are the spores hydrophilic or hydrophobic?
~ Are they aerosolized when wastewater splashes?
~ What happens to the spores in a typical WWTP? Are most of the spores separated with the sludge or
do the spores stay in water? Can the spores germinate and the vegetative bacteria replicate at
various locations throughout the WWTP?
~ What is the fate of the spores during disinfection?
~ Which method of disinfection is most effective for inactivation?
~ What is the rate of survival in a collection system? in human waste and wastewater? past secondary
treatment?
~ How will the levels of this pathogen be monitored?
~ What is the pathogen source?
~ When should the facility sample/analyze and for what?
~ What is the quantity and infection potential of spores?
~ Have the pathogens been introduced as a weapon or are they a naturally occurring variety?
~ What is the procedure for risk assessment and minimization?
~ Are the spores destroyed or inactivated in wastewater treatment?
~ Are pretreatments effective? If so, what type (on-site at an impacted industry, high level
biocontainment facility, at the plant, at a residence, etc.)?
~ What are the available tests and tools for characterization of biocontaminants and for helping answer
the questions above? (some of these are listed above or in the bibliography)
There was a suggestion for a laboratory analysis that was safe for laboratory personnel that could
be implemented readily with standard laboratory equipment. The ideal analysis would detect "high
consequence" organisms at levels of concern in a wastewater matrix that also includes many other
7-2
XW ERF
-------
organisms. This ideal analysis would quickly provide results and would distinguish between infectious
and non-infectious organisms. Current laboratory analysis is often far from this ideal.
7.3 Understanding and Preventing Worker Exposure
The group discussed how public and worker concerns may arise from an epidemiological
emergency or bioterrorism. In this situation, overriding public and worker concern about
biocontaminants can be boiled down to one question: "Will it make me sick or kill me?" To get to the
answer, more research is needed to determine the level of risk for WWTP workers, close-in area
residents, and downstream communities. Possible solutions will come from effective pretreatment,
upgraded and updated PPE, training and seminars, and coordinated public information campaigns.
The workshop participants suggested that the following health and safety questions be considered, along
with appropriate training.
~ What are the typical work tasks in WWTP and wastewater operations?
~ What are emergency tasks that might need to be done during a biological agent release or
bioterrorism event?
~ What are the routes of transmission (ingestion, contact, inhalation/aerosols, other vectors like insects
or rats, etc.)?
~ How does the pathogen survive in human waste? In wastewater? Through treatment processes? On
surfaces? In aerosols?
~ What is the dose-response for the specific pathogen, including different illness endpoints and
exposure routes?
~ What are the overall transmission risk/consequences?
~ How do anthrax responses compare to other pathogens already present in wastewater?
~ What are the risks and needed pretreatment and PPE protocols?
7.4 Management of Post-Treatment Impacts
One challenge will be to create a "cradle to grave" waste management plan. These plans should
include transportation and offsite disposal. Many states currently do not want treated waste transported
through their territory.
The workshop participants suggested that the following post-treatment questions be considered.
~ What are the impacts of the biocontaminated wastewater on receiving waters/downstream water
users?
~ How does treatment affect the quality of biosolids?
~ What are the effects of chemicals used during decontamination?
~ How should wastewater be released: At once or held and released slowly?
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
7-3
-------
-------
CHAPTER 8.0
Summary Statements and Next Steps
After a general discussion of future needs, suggestions, logistics, and suggested guidelines, the
participants created the following summary statements which contain suggested next steps for helping
utilities prepare for issues related to biocontaminated wastewater.
What is needed for
utilities to accept
biocontaminated
wastewaters?
Credible suggestions that utility workers, treatment processes, and communities will not
be adversely impacted by the biocontaminant(s) in question. These suggestions should
be provided by an interagency, interdisciplinary workgroup (including industry and
government experts, EPA, Centers for Disease Control and Prevention (CDC)/National
Institute for Occupational Safety and Health (NIOSH), OSHA, and others).
Next step action: In cooperation and coordination with the interagency group, develop
a state of the science assessment for utility response.
Next step action: In cooperation and coordination with the interagency group, develop
a utility response plan.
Other considerations: additional worker safety information; communication that is
coordinated and contains unified information; learning from Interagency Steering
Committee on Radiation Standards (ISCORS) analysis in the face of limited funding
and laboratory capacity; recognition that the issue is of national significance;
understanding that there will be gaps in knowledge for biocontaminant survivability in
wastewater; unanticipated, incident-specific indemnity issues for utilities associated
with their implementation of the utility response plan developed above;
acknowledgment of the differences of the utilities in response.
What types of tests and
protocols are needed
(and what is the design
for such tests)?
Appropriate assays, surrogates, and diagnostic tools, etc., to determine the infectivity,
persistence and fate of Bacillus anthracis and other high consequence pathogen(s) of
interest.
Next step action: Beyond Bacillus anthracis, develop an interagency, interdisciplinary
workgroup (including industry and government experts, EPA, CDC/NIOSH, OSHA,
and others) to evaluate a suite of potential, high-consequence pathogenic organisms that
may be introduced into wastewater.
What can be done now
to start regulatory
planning for the proper
management of
biocontaminated
wastewater?
Cascading authority should be aligned from the federal level down to the state and local
level and integrated into existing DHS or new frameworks.
Consensus (shared risk) between regulators and utility operators/owners.
Relationships built pre-incident between incident responders and wastewater utility
personnel.
What is needed to
address concerns and
issues raised by the
public, workers, and
operators?
Technical and non-technical information that is clear, acknowledges uncertainty, and is
geared to appropriate audiences.
Communication and emergency toolkits.
What are the gaps and
what types of research
are needed?
Synthesis of existing global data to identify gaps and develop information on
survivability, persistence, fate, viability, etc., across all media and processes; worker
exposure; sampling analysis/optimization, as well as risk assessment.
Real-time monitoring, robust analytical methods and techniques, development of new
technologies.
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
B-l
-------
APPENDIX A
Workshop Agenda
Collaborative Workshop on Handling, Management, and Treatment of
High Consequence Biocontaminated Wastewater by WRRFs
DAY ONE - Tuesday, November 17th, 2015
Registration (Please dial in at 8:45am)
Welcome and workshop objectives - Matthew Magnuson, EPA NHRSC
Workshop protocol, ground rules, and round robin introductions
Amit Pramanik and Lola Olabode, WERF
Overview of primary scenarios and implications on wastewater and Synopsis of a previous
workshop on "Acceptance of Biocontaminated Waste Water in North Carolina"
Ken Rhame, EPA OSC R4; Worth Calfee, Matthew Magnuson, EPA NHSRC
Mid-morning break
Perspectives on Biocontaminated Wastewater
(including testing and evaluation, limits of implementation and capabilities, case studies,
public communication and outreach, regulatory gaps, research gaps, etc.)
10:30 am Biocontaminated wastewater from other scenarios (e.g., hospital and medical waste, etc.) and
WH Ebola Medical Waste and other Category A infectious agents Sub-IPC
Chris Brown and Denise Matthews, OSHA
11:00 am Government Perspectives
State/city/region experience, lessons learned, and current process
Tanya Spano, Metropolitan Washington Council of Governments (10 min)
John Petito, New York City Department of Environmental Protection (10 min)
Overview of assessment of biocontaminated wastewater (non-emergency situations)
Bob Bastian, EPA Office of Wastewater Management (10 min)
EPA Pathogen Equivalency Committee - Eric Rhodes, EPA (10 min)
NHSRC research capabilities and facilities related to wastewater systems
JeffSzabo, EPA; Don Schupp, CBI; Mike Carpenter, INL; Willie Harper, USAF/AFIT (15 min)
Other/Q8A (10 min)
12:00 pm Working Lunch - (including 15 min personal break for participants to check emails/voicemails, etc.)
8:00 am
8:45 am
8:55 am
9:15 am
10:00 am
B-2
XWERF
-------
Utility and Other Stakeholder Perspectives
1:00pm Geeta Rijal - MWRD of Greater Chicago, IL
Lori Maag - MWRD, Denver, CO
Raj Bhattarai - City of Austin, TX
Naoko Muriakata - Los Angeles County SD, CA
(break at Chris Stacklin - Orange County SD, CA; Menu Leddy Orange County Water District (via web)
3pm) Greg Kester- California Association of Sewer Agencies (CASA), CA
Chris Carlough and Raul Gonzalez - Hampton Roads Sanitation District, VA
Jonathan Reeves - DC Water
Cynthia Finley- National Association of Clean Water Agencies (NACWA)
Charles Gerba, University of Arizona
Others
4:15 pm Question and Answer/Group Discussion
5:00 pm Recap of Day One - Matthew Magnuson and Amit Pramanik
5:30 pm Adjourn
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
7-3
-------
Collaborative Workshop on Handling, Management, and Treatment of
High Consequence Biocontaminated Wastewater by WRRFs
DAY TWO - Wednesday, November 18, 2015
8:00 am Registration (Please dial in at 8:30am)
Aspects of Utility Implementation
8:30 am Worker health and safety (biocontaminated wastewater focused) - Denise Matthews, Chris
Brown, OSHA;
Regulatory guidance - Bob Bastian, EPA OW
9:30 am Open Discussion
9:45 am Mid-morning Break
Group Discussion
10:00 am Brainstorming Session - Facilitated by Lola Olabode and Amit Pramanik, WERF
Initial list of questions:
What is needed/required for utilities to accept biocontaminated wastewaters ?
What types of tests and protocols and regulatory guidance are needed?
What is needed for permit authorities to guide/allow utilities to accept these wastes?
How should tests, protocols and regulatory guidance be designed or implemented?
Who should design and evaluate these?
What are the physical, logistical and requirement constraints in design and implementation?
Are there other "simpler" tests and protocols?
What is needed to address concerns and issues raised by the public, workers, and operators?
What other concerns need to be addressed?
What are the data gaps and what type of research (including experimental scale) is needed?
Other questions?
12:00 pm Working Lunch
Development of Summary Statements on Key Questions
12:45 pm Facilitated by Lola Olabode and Amit Pramanik, WERF
Questions identified as key during group discussion may include:
What is needed for utilities to accept biocontaminated wastewaters ?
What types of tests and protocols are needed (and what is the design for such tests) ?
What is needed for permit authorities to guide/allow utilities to accept these wastes?
What is needed to address concerns and issues raised by the public, by workers and
operators?
What are the gaps and what types of research are needed?
1:45 pm Review and Presentation of Summary Statements
1:50 pm Closing Remarks - Matthew Magnuson and Amit Pramanik
2:00 pm Adjourn
B-2
XWERF
-------
APPENDIX B
Workshop Participants
Bob Bastian
Environmental Protection Agency, Office of Wastewater Management, Washington, D. C.
Raj Bhattarai, P.E., BCEE
City of Austin, TX
Kyle Bibby
University of Pittsburgh, PA
Chris Brown
Occupational Safety and Health Administration, Washington, D. C.
Worth Calfee
Environmental Protection Agency, National Homeland Security Research Center, NC
Chris Carlough
Hampton Roads Sanitation District, VA
Mike Carpenter
Idaho National Laboratory, ID
Cynthia Finley
National Association of Clean Water Agencies (NACWA), Washington, D.C.
Charles Gerba
University of Arizona, AZ
Raul Gonzalez, Ph.D.
Hampton Roads Sanitation District, VA
Willie Harper
U.S. Air Force/Air Force Institute of Technology (AFIT), OH
Greg Kester
California Association of Sanitation Agencies (CASA), CA
Marissa Lynch
Environmental Protection Agency, Office of Water, Water Security Division, Washington, DC
Menu Leddy
Orange County Water District, CA
Lori Maag
Metro Wastewater Reclamation District, Denver, CO
Matthew Magnuson
Environmental Protection Agency, National Homeland Security Research Center, OH
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities 7-3
-------
Denise Matthews
Occupational Safety and Health Administration, Washington, D. C.
Leroy Mickelson
Environmental Protection Agency, Office of Emergency Management, CBRN Consequence Management
Advisory Division, RTP, NC
Anne Mikelonis
Environmental Protection Agency, National Homeland Security Research Center, NC
Naoko Munakata
Sanitation Districts of Los Angeles County, CA
John Petito, P.E.
New York City Department of Environmental Protection, NY
Jonathan Reeves, STS
DC Water, Washington, D.C.
Kenneth Rhame
Environmental Protection Agency, Region 4, On-Scene Coordinator, Raleigh, NC
Eric Rhodes
Environmental Protection Agency, National Homeland Security Research Center, OH
Geeta Rijal, Ph.D., RM (NRCM), BC
Metropolitan Water Reclamation District of Greater Chicago, IL
Don Schupp
CB&I, OH
Tanya Spano
Metropolitan Washington Council of Governments, Washington, D.C.
Chris Stacklin, P.E.
Orange County Sanitation District, CA
Jeff Szabo
Environmental Protection Agency, National Homeland Security Research Center, OH
Sarah Taft
Environmental Protection Agency, National Homeland Security Research Center, OH
B-2
XW ERF
-------
APPENDIX C
Workshop Presentations
~ Overview of Primary Scenarios and Implications on Wastewater and Synopsis of a Previous
Workshop on "Acceptance of Bio-contaminated Waste Water in North Carolina"
(Ken Rhame, EPA OSC R4; Worth Calfee, Matthew Magnuson, EPA NHSRC)
~ Ebola Medical Waste and Waste Contaminated with a Category A Infectious Agent
White House National Security Council Sub-Interagency Policy Committee (Sub-IPC)
Government Perspectives (Denise Matthews, OSHA)
~ State/City/Region Experience, Lessons-learned, and Current Process -
Government Perspectives - Metropolitan Washington Region
(Tanya Spano, Metropolitan Washington Council of Governments)
~ State/City/Region Experience, Lessons-learned, and Current Process - NYC Experience
(John Petito, New York City Department of Environmental Protection)
~ Overview of Assessment of Bio-Contaminated Wastewater (non-emergency situations)
(Bob Bastian, EPA OWM)
~ EPA Pathogen Equivalency Committee (Eric Rhodes, EPA NHSRC)
~ NHSRC and Collaborators' Facilities and Capabilities for Wastewater Research (Jeff Szabo,
EPA NHSRC; Don Schupp, CB&I; Mike Carpenter, INL; Willie Harper, USAF/AFIT)
Utility and Other Stakeholder Perspectives Presentation
~ Metropolitan Water Reclamation District of Greater Chicago, IL (Geeta Rijal)
~ Handling, Managing and Treating High Consequence Bio-contaminated Wastewater -
Utility Perspective Metro Wastewater Reclamation District. Denver, Colorado (Lori Maag)
~ What is Needed / Required for Utilities to Accept Bio-Contaminated Wastewaters?
Austin Water Utility, City of Austin, Texas. (Raj Bhattarai)
~ Bio-Contaminated Wastewater: A Utility Perspective. Los Angeles County Sanitation District,
California (Naoko Munakata)
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
C-l
-------
~ Utility Perspective: Regulatory, Spill Response, and Risk - Orange County Sanitation District,
California (Chris Stacklin)
~ Next Generation Sequencing with Illumina as a Tool for Microbial Community Analysis in
Reused Water -Orange County Water District (Menu Leddy via web)
~ Ebola Research Update from the California Association of Sanitation Agencies (CASA), CA
(Greg Kester)
~ A Utility Perspective: Hampton Roads Sanitation District, Virginia
(Chris Carlough and Raul Gonzalez)
~ Bio-Contamination Issues with Wastewater (Charles Gerba, University of Arizona)
~ Protecting Workers from Bio-Contaminated Wastewater Exposure: Occupational Hazards,
Infection Prevention, and Control Methods in Wastewater Operations (Chris Brown, OSHA)
C-2
Mm ERF
-------
Bibliography and
Further Reading
Albatanony, M.A. and El-Shafie, M.K. Work-related Health Effects among Wastewater Treatment
Plants Workers. Int. J. Occup. Environ. Med. 2011 Oct. 2(4):237-244.
Appendix E - Guidelines for Discharging Anthrax Decontamination Wastewater to Publicly Owned
Treatment Works (POTWs) - Technical Assistance for Anthrax Response, Interim-Final Draft. National
Response Team. n.d. Web. 13 Dec 2015.
yosemite.epa.gov/sab/sabproduct.nsf/17A8EBA9CAA030468525758D006D7AlB/$File/HSAC+Anthra
x+TAD+2005+4-21-09+Meeting.pdf. (Last accessed March 24, 2016)
Centers for Disease Control and Prevention. Interim Guidance for Managers and Workers Handling
Untreated Sewage from Individuals with Ebola in the United States. November 20, 2014. Web. 13 Dec
2015. www.cdc.gov/vhf/ebola/prevention/handling-sewage.html. (Last accessed March 24, 2016)
Centers for Disease Control and Prevention. Guidance for Reducing Health Risks to Workers Handling
Human Waste or Sewage. 2011. n.d. Web. 13 Dec 2015.
www.cdc.gov/haiticholera/workers_handlingwaste.html. (Last accessed March 24, 2016)
Hansen, E.S., Hilden, J., Klausen, H., and Rosdahl, N. Wastewater Exposure and Health -
A Comparative Study of Two Occupational Groups. Occup. Environ. Med. 2003; 60: 595-598.
Jeggli, S., Steiner, D., Joller, H., Tschopp, A., Steffen, R., and Hotz, P. 2004. Hepatitis E, Helicobacter
pylori, and Gastrointestinal Symptoms in Workers Exposed to Waste Water. Occup. Environ. Med.
2004;61:622-627.
Interagency Steering Committee on Radiation Standards, n.d. Web. 13 Dec 2015.
www.iscors.ore/library.htm#documents. (Last accessed, March 24, 2016)
The Medical Waste Tracking Act of 1988. n.d. Web. 13 Dec 2015
http://www3.epa.gov/epawaste/nonhaz/industrial/medical/mwpdfs/mwta.pdf. (Last accessed March 24,
2016)
Muhammad, N., Gallardo, V.J., Schupp, D.A., Krishnan, E.R., Minamyer, K. S., and Riceb, E.W.
Inactivation of Bacillus Spores in Decontamination Wash Down Wastewater Using Chlorine Bleach
Solution. Canadian Journal of Civil Engineering, 2014, 41(1): 40-47, 10.1139/cjce-2013-0319.
National Institute of Allergy and Infectious Diseases. Category A, B, and C Priority Pathogens, n.d.
Web. 13 Dec 2015. fas.org/biosecurity/resource/documents/NIAID_priority_pathogens-l-07.pdf. (Last
accessed, March 24, 2016)
Collaborative Workshop on Handling, Management, and Treatment of Bio-Contaminated Wastewater
by Water Resource Recovery Facilities
R-l
-------
National Institutes of Health Exposure Control Program for Non-Hospital Personnel.
NIH Institutional Biosafety Committee, rev. June 2015. Web. 13 Dec 2015.
www.ors.od.nih.gov/sr/dohs/Documents/NIH%20Exposure%20Control%20Plan.pdf. (Last accessed
March 24, 2016)
National Research Council. A Review of the EPA Water Security Research and Technical Support
Action Plan: Parts I andII. Washington, D.C.: The National Academies Press, 2003.
doi: 10.17226/10772.
Samuels, W.B. Early Warning System (EWS) Guidance to Wastewater Utilities. 2009. WERF Report
04CTS9Sa. Water Environment Research Foundation, Alexandria, VA.
Sedmak, G., Bina, D., MacDonald, J., and Couillard, L. Nine-Year Study of the Occurrence of
Culturable Viruses in Source Water for Two Drinking Water Treatment Plants and the Influent and
Effluent of a Wastewater Treatment Plant in Milwaukee, Wisconsin (August 1994 through July 2003).
Applied and Environmental Microbiology. 2005.Feb.; 71(2) 1042-1050.
Sinclair, R.G., Choi, C.Y., Riley, M.R., and Gerba, C.P. Pathogen Surveillance through Monitoring Of
Sewer Systems. Advances in Applied Microbiology. 2008. 65: 249-269..
U.S. Department of Labor. Anthrax eTool - OSHA, n.d. Web. 13 Dec 2015.
https://www.osha.gov/SLTC/etools/anthrax/. (Last accessed March 24, 2016)
United States Environmental Protection Agency, Health Risks of Human Exposure to Wastewater. EPA-
600/S1-81-002 United States Environmental Protection Agency, Health Effects Research Laboratory,
Cincinnati, OH. Mar 1981.
United States Environmental Protection Agency. Model Guidelines for State Medical Waste
Management, n.d. Web. 13 Dec 2015. Part 1:
http://www3.epa.gOv/epawaste/nonhaz/industrial/medical/mwpdfs/modguidl/l.pdf; Part 2:
http://www3.epa.gov/epawaste/nonhaz/industrial/medical/mwpdfs/modguidl/2.pdf; Part 3:
http://www3.epa.gOv/epawaste/nonhaz/industrial/medical/mwpdfs/modguidl/3.pdf; Part 4:
http://www3.epa.gOv/epawaste/nonhaz/industrial/medical/mwpdfs/modgiiidl/4.pdf. (Last accessed
March 24, 2016)
Verani, M., Bigazzi, R., and Carducci, A. Viral Contamination of Aerosal and Surfaces through Toilet
Use in Health Care and Other Settings. American Journal of Infection Control. 2014. 42(7): 758-762.
Vulnerability Self-Assessment Tool. n.d. Web. 13 Dec 2015.
yosemite.epa.gov/ow/SReg.nsf/description/VSAT. (Last accessed March 24, 2016)
R-2
XW ERF
------- |