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Jewish Death Practices:
Learning & Resources:
We need to be conscious of Infection Control issues when we do Taharah. Below are 20+ articles covering a 30 year time span. They show the range of analysis, recommendations and the evolution of thinking on this topic.
|6.5.5 Management of dead bodies
There is no risk to the burial team if infection-control procedures are followed
(see Annex 3).
|World Health Organization||2008|
|...how the latest material technology (shape-changing polymers, adhesives, etc.) may be leveraged to improve current and future respirator designs including the long-term possibility of moving away from current fit-testing requirements, while preserving user protection.||August 2008|
|Osterholm said areas to be concerned about include worker and patient protection (from the virus), and medical devices and staffing.
Even the dead will be contagious.
"Corpse management, the handling of the dead and how we grieve, will be very important," he said.
|Dr. Michael Osterholm||September 2006|
|Guidance for pathologists and anatomical pathology technologists for autopsy of cadavers with known or suspected pandemic (avian) influenza|| There is concern about the procedures to be followed in the mortuary if and when there is a request to examine the body of a person who is known or suspected to have died from pandemic influenza. This includes avian influenza, on the premise that the A/H5N1 virus may evolve to produce the next human pandemic.
Although no one knows if there will be a pandemic, in the event of one the Department of Health and the Health Protection Agency (HPA) estimate the likely excess mortality in the UK to be at least 50,000 deaths.
The most critical cases will be those occurring early on during an epidemic; once health professionals become proficient at making a clinical diagnosis, the need for confirmatory in vivo laboratory and autopsy diagnosis will diminish.
The Department of Health has produced guidance that includes much useful background information, as well as specific protection advice for those healthcare workers who may be exposed to aerosols containing the influenza virus, e.g. during an autopsy examination.
| The Royal College of Pathologists
Professor Sebastian Lucas, on behalf of the
the vast majority of human cases have acquired their infection following direct contact with infected live or dead poultry
|World Health Organization||April 2007|
| Bodies of Dead H5N1 Avian Influenza Patients Pose Minimal Risk for Virus Spread
Intelligence Findings and Analysis
| If highly pathogenic H5N1 avian influenza (AI) becomes easily transmissible from person to person, viral spread from dead bodies to people handling the remains is possible, but is unlikely to be a major contributor to additional cases. Personnel handling the remains of patients who die of H5N1 AI are assessed to be at minimal risk for infection. AFMIC bases this assessment, in part, on the assumption that H5N1 AI transmission characteristics will largely mimic those of other human influenza viruses.
• Specific data on H5N1 AI transmission from infected human remains are lacking. However, the H5N1 AI virus has been isolated from human cerebrospinal fluid, fecal, throat, and serum specimens from infected patients.
• According to the World Health Organization (WHO), if H5N1 AI becomes easily transmissible from person to person, it will be possible to become infected through unprotected contact with infectious respiratory secretions and body fluids from dead bodies or objects contaminated with those secretions. Conservative estimates by the WHO suggest secretions from dead bodies of AI patients who die within 7 days after fever resolution (adults) or up to 21 days after symptom onset (children) could transmit virus.
• In other strains of influenza, use of widely recognized transmission-based standard precautions (including personal protective equipment) in handling the bodies of dead patients mitigates the risk of influenza infection.
| AFMIC Medical Intelligence Note 030-06, DI-1812-1105-06
03 March 2006
|Infection Control Guidance for Handling of Human Remains of Severe Acute Respiratory Syndrome (SARS) Decedents|| The emergence of SARS has resulted in numerous challenges and concerns for the public, health care providers and for members of the funeral service profession. The evidence to date indicates that following routine practices1 (sometimes known as universal or standard precautions) should be used for all work involving contact with the human remains of a SARS patient. The following are general recommendations to assist funeral service workers performing mortuary procedures, ensure their safety and avoid contamination of the workplace.
Provincial regulations must be followed when dealing with people in quarantine. If any member, friend, etc., is in quarantine, they should be advised not to come to the funeral home and to either make arrangements by phone or appoint a person who is not in quarantine to come to the funeral home to make the arrangements on their behalf. People in quarantine cannot attend a funeral. They can be advised to postpone the funeral until after the end of their quarantine period or proceed with the funeral without the attendance of the persons in quarantine. Assistance in this matter can be requested to the local Public Health.
|Health Canada||June 2003|
|Precautions for Handling and Disposal of Dead Bodies|| All dead bodies are potentially infectious and universal precautions should be implemented for every case. Although most organisms in the dead body are unlikely to infect healthy persons, some infectious agents may be transmitted where workers are in close contact with blood, body fluids and tissues of dead body who died with infectious diseases. To minimize the risks of transmission of known and also unsuspected infectious diseases, dead bodies should be handled in such a way that workers' exposure to blood, body fluids and tissues is reduced. A rational approach should include staff training and education, safe working environment, appropriate work practices, the use of recommended safety devices and vaccination against hepatitis B.
There is a need to maintain the confidentiality of a patient's medical condition even after his/her death. At the same time, there is obligation to inform personnel who may be at risk of infection through contact with dead bodies so that appropriate measures may be taken to guard against infection. The discrete use of labels such as "Danger of infection" on the dead body is considered appropriate.
The followings outline work practices which are recommended when handling and disposing dead bodies. The objectives of drawing up this set of guidelines are: (i) to enable the deceased's family to obtain funeral services, and (ii) to protect the involved personnel, e.g. workers and relatives. Hospitals, public mortuaries, funeral parlours, and undertakers of burial are urged to adopt them in light of local circumstances and requirements. The adopted precautions should be widely disseminated to all staff involved.
|Infective agents in fixed human cadavers: a brief review and suggested guidelines|| Cadavers remain a principal teaching tool for anatomists and medical educators teaching gross anatomy. Infectious pathogens in cadavers that present particular risks include Mycobacterium tuberculosis, hepatitis B and C, the AIDS virus HIV, and prions that cause transmissible spongiform encephalopathies such as Creutzfeldt-Jakob disease (CJD) and Gerstmann-Straussler-Scheinker syndrome (GSS).
It is often claimed that fixatives are effective in inactivation of these agents. Unfortunately cadavers, even though they are fixed, may still pose infection hazards to those who handle them. Specific safety precautions are necessary to avoid accidental disease transmission from cadavers before and during dissection and to decontaminate the local environment afterward. In this brief review, we describe the infectious pathogens that can be detected in cadavers and suggest safety guidelines for the protection of all who handle cadavers against infectious hazards.
| Anat Rec. 2002 Aug 15;269(4):194-7.
Demiryurek D, Bayramoglu A, Ustacelebi S.
|Funeral Parlours|| The main hazards encountered in funeral service activities are the risk of infection, manual handling and exposure to hazardous substances/chemicals. The risk of infection arises from the small proportion (less than 1%) of the 600,000 people who die each year in the UK who have a known or suspected infectious disease.
(Where embalming forms the main activity, the health & safety enforcement responsibility lies with the HSE).
|the Nuneaton & Bedworth Borough Council||updated March 2002; Oct 1997;|
|Code of Practice for Funeral Workers: Managing Infection Risk and Body Bagging|| There is substantial variation in the advice given to funeral workers on
handling bodies with infection risk. Inconsistent advice results in inappropriate practice.
A model code of practice is presented that uses risk assessment in response to statutory and executive responsibilities to provide health and safety advice to funeral workers.
The code of practice should increase compliance with safety requirements, avoid
unnecessary bagging and allow bereaved families freer access to the deceased.
|Communicable Disease and Public Health Journal - Vol 4 No 4
Birmingham Health Authority
| Protecting Mortuary Affairs Personnel
from Potentially Infectious Materials
|Contact with whole or part human remains carries potential risks associated with pathogenic microbiological organisims that may be present in human blood and tissue. Infectious conditions and pathogens in the recently deceased include -
• bloodborne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), hepatitis E virus (HEV) and human immunodeficiency virus (HIV);
Each exposure poses its own risks depending on the virulence of the pathogen, the size of the dose delivered, the route of exposure, and the exposed individual's susceptibility. Since a single exposure may cause infection, the best way to reduce risk is to prevent exposures from occurring. The primary ways to protect personnel who handle human remains against infectious diseases are -
| U.S. Army Center for Health Promotion and Preventive Medicine
Aberdeen Proving Ground, Maryland 21010-5403
Johns Hopkins researchers have reported the first known case of tuberculosis (TB) transmitted from a cadaver to an embalmer, according to a case study in the Jan. 27 issue of the New England Journal of Medicine.
"Before this study, the transmission of TB from a cadaver to an embalmer had never been demonstrated," says Timothy Sterling, M.D., an assistant professor of infectious diseases at the Johns Hopkins School of Medicine and lead author of the study. "Previous studies had shown that funeral home workers had unexpectedly high rates of TB infection and disease, but it was not known if this was due to exposure in the workplace."
TB is spread through the air by infectious aerosols, tiny particles that enter the body through the nose or mouth and lodge deep in the lungs. In the new study, doctors identified an individual with active TB whose only known exposure to the bacterium was through the embalming of an infected cadaver.
During the embalming process, blood is removed and fluids are injected into the body to preserve it. "Aerosols can be generated by the injection of fluids, or by the frothing and gurgling of fluids through the mouth and nose," said Sterling. "In addition, the cadaver can spasm during the embalming process, which can cause the release of respiratory secretions." Embalming fluids are often dumped into a drain after the embalming process and this also could release infectious aerosols.
The doctors identified this unusual route of transmission through an ongoing tuberculosis surveillance initiative. As part of this initiative, every case of the disease in Baltimore reported to the Baltimore City Health Department undergoes DNA fingerprinting at Johns Hopkins. When two or more TB cases have similar DNA fingerprints, researchers become concerned about whether recent transmission of TB has occurred.
For this reason, when researchers discovered that two TB patients had the same DNA fingerprint, they set out to investigate possible times of exposure between the two patients. They subsequently noticed that the mortician had signed the death certificate of the other patient. The diagnosis of TB was not established in the first patient until after death.
"Currently the Centers for Disease Control and Prevention and the Occupational Safety and Hazard Administration guidelines for the prevention of the spread of TB are not applied to funeral homes," said Sterling. "This case report suggests that they should be, to prevent the transmission of TB through the embalming process."
Tuberculosis is the second leading cause of death from an infectious disease. Worldwide, 2 million people die of TB annually, and 7 million to 8 million new TB cases are diagnosed each year. Therapy for tuberculosis requires a multidrug regimen of four drugs. For more TB facts or more information about TB research at Johns Hopkins, visit http://www.hopkins-tb.com.
Dr. Tim Sterling - Johns Hopkins - 410-614-0922
Trent Stockton - public affairs - 410-955-8665
Other authors of the study are Diana Pope, R.N., M.S.; Susan Harrington, M.P.H.; William Bishai, M.D., Ph.D.; Robyn Gershon, M.H.S., Dr.P.H.; and Richard Chaisson, M.D. Funding for the study was provided by the Baltimore City Health Department, the Centers for Disease Control and Prevention, and the National Institutes of Health.
|Infection Control Guidelines for Funeral Directors|| There are some infectious conditions in a cadaver that may pose a hazard to the people who handle it. These guidelines have been written for Funeral Directors and Embalmers whose occupational contact with cadavers may put them at a slightly increased risk of contracting these conditions.
In this document the term 'embalming' refers to both arterial and cavity embalming. Preparation of a body will also include one or all of the following; septal suturing (or equivalent), packing, washing and handling of the cadaver. The greatest risk in these procedures is from those which require the use of sharp instruments, with the potential risk of injury to the embalmer during preparation of the body.
At the end of this document there is a list of infections, which have been categorised by degree of risk and, alongside this, an indication as to whether the body can, without risk, be embalmed. It should be stressed, however, that the risk from all of these infections is minimal and the terms 'Low', 'Medium' and 'High' have only been applied to determine comparative degrees of risk.
It is important to remember that risks can be minimised by following good basic infection control precautions. These precautions should be used in all instances, as it may not be known if a given cadaver harbours an infection or not.
| Essex Health Protection Unit
Community Infection Control Teams of North and South Essex Control Teams
|Transmission of Mycobacterium Tuberculosis to a Funeral Director During Routine Embalming||
Several studies have shown that funeral directors have an increased risk of tuberculosis (TB). Although there is indirect evidence of transmission of TB from cadavers to mortuary workers, there is only one recently documented case in the literature. We report here another case of occupationally acquired TB in a funeral director, which was confirmed by conventional epidemiology and genotyping. This case illustrates the risk of TB transmission to mortuary workers from routine embalming of deceased TB patients with active disease.
| Chest - The Cardiopulmonary and Critical Care Journal
Lauzardo M, Lee P, Duncan H, Hale Y.
|Reporting of Infectious Disease Status of the Deceased||At the November 16, 1999 meeting of the Board of Funeral Directors and Embalmers an issue was raised concerning the disclosure of the infectious disease status of the deceased to the funeral home practitioner. Members of the Board voiced concern about the potential health risk when the infectious disease status is not disclosed. The Board of Funeral Directors and Embalmers recommended that the Board of Health Professions review the literature, investigate the relevant portions of the Code of Virginia and dialogue with the state agency responsible for enforcing the Code to determine if further study into the issue is warranted. The following is a preliminary report that highlights current literature in the field and provides a summary of information pertaining to the reporting of infectious diseases in Virginia.||Virginia Board of Health Professions||November 1999|
|Tuberculosis Risk in Funeral Home Employees||
In order to estimate the risk of tuberculosis infection among employees in the funeral service industry, we conducted a risk-assessment study of a convenience sample of funeral home employees. Study participants completed a risk-assessment questionnaire and underwent tuberculin skin testing.
Of 864 employees tested, 101 (11.7%) had a reactive tuberculin skin test. Reactivity to the tuberculin skin test was significantly associated with job category; funeral home employees with a present or past history of embalming deceased-human remains were twice as likely to be reactive as were non-embalming personnel (14.9% versus 7.2%, P < 0.01). Reactivity was also associated with age, gender, race, past history of close contact with a person diagnosed with tuberculosis, and work history. After controlling for age and other factors, tuberculin reactivity was found to be associated in embalming personnel with the number of years spent performing embalmings (> or = 20), and, in non-embalming personnel, with a history of close contact with infected individuals.
Based on these results, it is recommended that funeral home employees who routinely embalm cadavers undergo annual tuberculin skin testing, receive initial training on tuberculosis prevention, and wear respiratory protection when preparing known tuberculosis cases.
| Journal of Occupational and Environmental Medicine; 1998 May 40(5):497-503
Gershon RR, Vlahov D, Escamilla-Cejudo JA, Badawi M, McDiarmid M, Karkashian C, Grimes M, Comstock GW.
|Infection in the deceased: a survey of management||
Funeral directors, control of infection officers, chief environmental health officers, and consultants in communicable disease control were surveyed to identify the sources and nature of advice about infectious hazards from the deceased available to undertakers. They were asked about management responsibilities, policies, particular activities (viewing, hygienic preparation, bagging, embalming, and final disposal by burial or cremation), specific diseases (hepatitis B, HIV infection, tuberculosis, meningitis, septicaemia, and salmonellosis), and repatriation. A wide range of opinions and advice was received on each topic. Medical personnel need a greater understanding of the work of funeral directors. Policies based on a realistic assessment of risk should be agreed.
1995 Apr 28;5(5):R69-73.
Young SE, Healing TD.
|Occupational Risk of Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infections Among Funeral Service Practitioners in Maryland|| OBJECTIVE: To estimate the risk of exposure and infection with bloodborne pathogens, a seroepidemiologic survey was conducted among funeral service practitioners (FSPs) in Maryland.
METHOD: Of 262 members of the Maryland State Funeral Directors Association, 130 (49%) volunteered to participate in the study. In addition to a brief questionnaire, designed to assess both occupational and non-occupational risk factors for bloodborne pathogen infection, participants were screened for markers of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and past hepatitis B virus (HBV). Titers for antibodies to hepatitis B surface antigen (anti-HBs) also were examined and compared with history of hepatitis B vaccination.
RESULTS: Seroprevalence for HIV, HBV, and HCV infection was 0.8%, 4.6%, and 0%, respectively. Nearly 19% of participants reported at least one bloodborne exposure in the past 6 months. The one HIV infection and all but two of the HBV infections were correlated with well-established non-occupational risk behaviors. Disposable gloves were worn by 96%, and eating, drinking, or smoking during embalming were infrequent. Sixty-one percent of FSPs reported having received one or more doses of hepatitis B vaccine at some time in the past. Of those who reported having received all three doses of vaccine, 67% had adequate titers to hepatitis B surface antibody, the marker of protection related to vaccination.
CONCLUSION: Compared with prior studies of FSPs, this study found a low rate of occupational exposures and a high rate of hepatitis B vaccination, suggesting improved compliance with recommendations for preventing transmission of bloodborne pathogens in the workplace.
| Infection Control in Hospital Epidemiology 1995;16(4):194-7
Gershon, R. R. M., Vlahov, D., Farzadegan, H., & Alter, M. J.
|The Infection Hazards of Human Cadavers||Cadavers may pose infection hazards to people who handle them. None of the organisms that caused mass death in the past--for example, plague, cholera, typhoid, tuberculosis, anthrax, smallpox--is likely to survive long in buried human remains. Items such as mould spores or lead dust are much greater risks to those involved in exhumations. Infectious conditions and pathogens in the recently deceased that present particular risks include tuberculosis, group A streptococcal infection, gastrointestinal organisms, the agents that cause transmissible spongiform encephalopathies (such as Creutzfeldt-Jakob disease), hepatitis B and C viruses, HIV, and possibly meningitis and septicaemia (especially meningococcal). The use of appropriate protective clothing and the observance of Control of Substances Hazardous to Health regulations, will protect all who handle cadavers against infectious hazards.||United Kingdom Communicable Disease Report||April 1995|
|Infection Hazards of Human Cadavers - Safety in a Clinical Virology Laboratory|| Cadavers may pose infection hazards to people who handle them, such as pathologists, nurses, mortuary attendants, embalmers, funeral directors and members of the emergency services. Viruses which poses particular risks include HIV, HBV, HCV, CJD, rabies, yellow fever and viral haemorrhagic fevers.
In general, following COSHH (Control of Substances Hazardous to Health) precautions, especially the use of protective clothing will greatly reduce the risk of acquiring infection. Some additional precautions may be advisable for particular infections.
The Howie report (1978) presented a detailed code of practice for the prevention of infection in laboratories and necropsy rooms. There are detailed protocols for the layout, construction, ventilation and operation of necropsy rooms, Hands should be washed routinely after each procedure and the environment cleaned with a phenolic disinfectant daily. The instruments should be washed in a washer-disinfector, autoclaved or immersed in a phenolic disinfectant for 20 minutes. A phenolic disinfectant is preferred to hypochlorite because hypochlorite is corrosive and may damage surfaces and instruments.
At present, funeral directors are not given access to the death certificate and therefore they may not be alerted to potential infection hazards. Body bags are becoming more and more commonly used but they may be unpleasant to the relatives. All instruments used for embalming or preparing the body for the funeral should be cleaned and warm water and detergent and then disinfected by a phenolic disinfectant. Although an autoclave provides excellent decontamination, this is not justified by the existing levels of risk.
|Universal Precautions and Mortuary Practitioners: Influence on Practices and Risk of Occupationally Acquired Infection|| Embalming, the most common funeral practice in the United States, may expose the embalmer to infectious diseases and blood. We surveyed the 860 members of the National Selected Morticians in 1988 to estimate the incidence of self-reported occupational contact with blood and infectious disease, assess morticians' knowledge of acquired immunodeficiency syndrome (AIDS), determine their adherence to universal precautions, and identify predictors of practices designed to reduce risk of occupational exposure to infections.
Of 539 (63%) respondents, 212 (39%) reported needle-stick injuries in the past 12 months, and 15 (3%) reported percutaneous exposures to the blood of a decedent with AIDS. Those rating the risk of occupationally acquired human immunodeficiency virus infection as very high or high (194/539 [36%]) were more likely to decline funerals of decedents with antemortem diagnosis of AIDS (59/194 [30%]) and/or to charge more for such funerals (133/194 [69%]) than those who rated the risk as low to moderate (31/345 [9%], 174/135 [51%]).
| Journal of Occupational Medicine 1991;33(8):874-8
Beck-Sague CM, Jarvis WR, Fruehling JA, Ott CE, Higgins MT, Bates FL
|We performed a serosurvey of 133 embalmers in an urban area where human immunodeficiency virus (HIV) infection is prevalent. Although we found histories of needlesticks to be common, and the seropositivity rate of hepatitis B virus (HBV) (13%) was approximately twice that of a blood donor comparison group, HIV antibody was uniformly absent in 129 embalmers who denied HIV risk factors, and present in one of four with self-described risk behaviors. The risk of HBV infection was higher among embalmers who have worked more than 10 years, relative risk (RR) 16.2 (95% confidence interval 2.1, 126.5), did not routinely wear gloves, RR 9.8 (CI 3.4, 28.5), or are employed in the city of Boston, RR 4.7 (CI 1.8, 12.0).|| Am J Public Health. 1989 October; 79(10): 1425-1426.
S B Turner, L M Kunches, K F Gordon, P H Travers, and N E Mueller
Division of Community Health Services, Boston Department of Health and Hospitals, MA.
|Exposure to and precautions for blood and body fluids among workers in the funeral home franchises of Fort Worth, Texas.||In 1982 the Centers for Disease Control published a set of recommendations and measures to protect persons working in health care settings or performing mortician services from possible exposure to the human immunodeficiency virus. This study of a number of funeral homes in the Fort Worth area was designed to determine the level of exposure of funeral home workers to blood and other body fluids and also to assess existing protective measures and practices in the industry. Workers in 22 funeral home franchises were surveyed with a predesigned questionnaire. Eighty-five responses from 20 of the 22 establishments were received. All 85 respondents admitted exposure of varying degrees to blood and body fluids. Sixty persons (70%) admitted heavy exposure, that is, frequent splashes. Analysis of the responses showed that 81 of 85 (95.3%) persons consistently wore gloves while performing tasks that might expose them to blood or other body fluids. Of the 60 persons who were heavily exposed, 43 wore long-sleeved gowns, 27 wore waterproof aprons, 17 surgical masks, and 15 goggles. The study further revealed that 52.9% (45/85) of the respondents had sustained accidental cuts or puncture wounds on the job. In light of these findings it is important to target educational efforts to persons in this industry to help them minimize their risks of infection with blood and body fluid borne infections.||American Journal of Infection Control;17(4):208-12||August 1989|
Six of 106 undertakers (5.6%) gave a past history of hepatitis during their professional careers; this was no different from the frequency in a control group of 3,162 accountants (5.1%) who had no direct contact with blood. None of the undertakers or 210 blood donors matched for age, sex, and ethnic background had serum positive for hepatitis B surface antigen. Five undertakers (4.7%) had blood that was positive for antibody to hepatitis B surface antigen, compared with six of 210 (2.9%) in the control group; this difference was not statistically significant (P greater than .25). Thus, undertakers appear to be in a low-risk occupation with reference to acquisition of hepatitis B. Although the numbers are too small for statistical analysis, there appeared to be an increased exposure to hepatitis B in undertakers who take no preventive precautions. We recommend that the minimal precautions for undertakers be the wearing of gloves.
1978 Jul 14; 240(2):138-9
Berris B, Feinman SV, Richardson B, Wrobel DW, Sinclair JC.