It took a crew 38 hours to clear out the Dallas apartment where Thomas Eric Duncan was staying before he was diagnosed Sept. 30 with Ebola. Hazmat suit-clad workers piled shoes, carpets, mattresses, bed sheets, clothes and kids' backpacks into 140 55-gallon drums. Only a few items were salvaged: a computer hard drive, legal documents, family photos, an old Bible belonging to Duncan's grandmother.
The drums were packed, decontaminated and then carted away by Cleaning Guys environmental services employees. The contents were incinerated. But nearly a month later, the ashes sit in limbo at a facility in Port Arthur, Texas, according to Veolia North America, the company that owns the facility, as Louisiana officials fight to keep it out of a landfill there.
While the Centers for Disease Control and Prevention says incinerated Ebola waste poses no danger, Louisiana officials earlier this month asked a judge to block Duncan's waste from entering the state, saying they wanted to determine for themselves that it was not dangerous. On Friday, state officials announced that Veolia has agreed to keep the ash out of the state's landfill.
Louisiana Attorney General Buddy Caldwell said in a statement that the agreement "ends this chapter in the controversy of transportation and disposal of Ebola waste."
But the unresolved fate of the ashes highlights the problem U.S. hospitals and communities could face in disposing of their own Ebola-related refuse.
Hospitals routinely deal with hazardous medical waste, sealing, transporting and disposing of vials of HIV-infected blood or boxes of used syringes. But Ebola waste is more problematic because of the intense fear of the virus and the sheer amount of the waste, which could include patients' clothes, their mattresses and scores of protective outfits worn and discarded by medical workers.
According to the American Hospital Association, a typical hospital patient produces roughly three pounds of waste a day, much of it not considered hazardous. However, an Ebola patient could generate eight 55-gallon drums of waste, all of it treated as highly infectious.
By contrast, there isn't much debate about what to do with ashes of Ebola waste, said Julie Damond, a spokeswoman for Doctors Without Borders in Dakar, Senegal. Such waste is routinely incinerated.
"We know that the virus doesn't survive heat more than about 60 degrees (Celsius) for several minutes and it is very sensitive to detergents such as chlorine. So we use both to get rid of it," she said.
In the U.S., Ebola waste is categorized as a Class A infectious substance under federal transportation guidelines, meaning it can cause death or permanent disability. But traditional packaging requirements for Class A waste make it hard to transport such large volumes. Class A material, often needles and blood vials, are packaged inside two small water-tight containers and then placed inside a third container for transport. CDC guidelines call for Ebola-related waste to be decontaminated and bagged, then bagged a second time and placed into 55-gallon drums.
Of 123 hospitals of various sizes across the country contacted by Associated Press reporters, three said they lacked a plan for Ebola, and several others said their plans were evolving. Eleven said they had on-site incinerators for waste disposal. More than a hundred said they relied on outside contractors.
But some companies have said they can't or won't pick up Ebola waste.
After Duncan's diagnosis, Dallas County spokeswoman Lauren Trimble said the county contacted seven vendors to clean out the apartment. Cleaning Guys was "the only vendor that was responsive and met the guidelines" for that kind of waste disposal.
Clay Jenkins, the Dallas County judge overseeing the Ebola response, said fear, as well as logistics, caused some companies to balk.
"Any time we move away from science and into fear and panic, we're making it harder for our first responders to do their jobs," Jenkins said. "The idea that you can't take ash, or waste disposal companies that deal with medical waste won't handle Ebola waste — it's just crazy for people to be afraid of ashes."
Last week, the Department of Transportation developed a new permit to help solve at least the logistics part of the problem, allowing qualified companies to pick up and transport Ebola-contaminated waste from any location, be it hospital or an apartment, in place of the usual site-specific permits.
The new permits were designed to help avoid scenarios that played out in Duncan's apartment and at Atlanta's Emory University Hospital shortly after its first Ebola patients arrived in August, when the company contracted to collect its Class A medical waste refused to take the Ebola waste.
"We had some really unexpected adventures in waste management," Dr. Aneesh Mehta, the hospital's assistant director of transplant and infectious diseases, told the American Society of Microbiology in September. "We had a buildup. We in fact went to Home Depot and bought up every large trash can/sealed canister we could get and kept them in a separate room until we renegotiated our contract with our waste-management company."
That company, Stericycle, would not comment on its contract with Emory, but said in a statement it has received national approval to transport Ebola waste and is working with authorities "to address each potential and new Ebola case."
South Carolina-based Advanced Environmental Options Inc. was granted an emergency DOT permit last week to haul away Ebola waste across the Carolinas, Georgia, Tennessee, Alabama, Virginia, Kentucky and Florida. Account manager Dana West said the company can handle large volumes of hazardous waste in a variety of scenarios.
"Our client list includes government agencies, universities, schools, private industries. We do medical waste, crime scene cleanup, meth labs — you name it, we've done it," West said.
But where Ebola waste will go after it is treated is still unclear.
While Louisiana fights on, Missouri Attorney General Chris Koster has reached an agreement with a sterilization company blocking it from handling Ebola waste at its St. Louis facility.
Linda Greene, who sits on the Association for Professionals in Infection Control and Epidemiology Regulatory Review Panel, said the new DOT permits provide a measure of security for hospitals wondering whether their existing contractors would handle Ebola waste. But protocols are still evolving.
"You start putting plans in place for something you haven't dealt with before and begin asking all these questions," Green said. "There's a lot of discussion and problem solving that still has to occur."
Associated Press reporters Lauran Neergaard in Washington, Nomaan Merchant in Dallas and Melinda Deslatte in Baton Rouge, La., contributed to this report.