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08/21/2014

CDC and WHO Ebola Recommendations

Last Updated October 15th, 2014

Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries

http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html

These recommendations give guidance on the safe handling of human remains that may contain Ebola virus and are for use by personnel who perform postmortem care in U.S. hospitals and mortuaries. In patients who die of Ebola virus infection, virus can be detected throughout the body. Ebola virus can be transmitted in postmortem care settings by laceration and puncture with contaminated instruments used during postmortem care, through direct handling of human remains without appropriate personal protective equipment, and through splashes of blood or other body fluids (e.g. urine, saliva, feces) to unprotected mucosa (e.g., eyes, nose, or mouth) which occur during postmortem care.
  • Only personnel trained in handling infected human remains, and wearing PPE, should touch, or move, any Ebola-infected remains.
  • Handling of human remains should be kept to a minimum.
  • Autopsies on patients who die of Ebola should be avoided. If an autopsy is necessary, the state health department and CDC should be consulted regarding additional precautions.

Definitions for Terms Used in this Guidance

Cremation: The act of reducing human remains to ash by intense heat.

Hermetically sealed casket: A casket that is airtight and secured against the escape of microorganisms. A casket will be considered hermetically sealed if accompanied by valid documentation that it has been hermetically sealed AND, on visual inspection, the seal appears not to have been broken.

Leakproof bag: A body bag that is puncture-resistant and sealed in a manner so as to contain all contents and prevent leakage of fluids during handling, transport, or shipping.

Personal protective equipment for postmortem care personnel

  • Personal protective equipment (PPE): Prior to contact with body, postmortem care personnel must wear PPE consisting of: surgical scrub suit, surgical cap, impervious gown with full sleeve coverage, eye protection (e.g., face shield, goggles), facemask, shoe covers, and double surgical gloves. Additional PPE (leg coverings, apron) might be required in certain situations (e.g., copious amounts of blood, vomit, feces, or other body fluids that can contaminate the environment).
  • Putting on, wearing, removing, and disposing of protective equipment: PPE should be in place BEFORE contact with the body, worn during the process of collection and placement in body bags, and should be removed immediately after and discarded appropriately (see Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus(http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html). Use caution when removing PPE as to avoid contaminating the wearer. Hand hygiene (washing your hands thoroughly with soap and water or an alcohol based hand rub) should be performed immediately following the removal of PPE. If hands are visibly soiled, use soap and water.

Postmortem preparation

  • Preparation of the body: At the site of death, the body should be wrapped in a plastic shroud. Wrapping of the body should be done in a way that prevents contamination of the outside of the shroud. Change your gown or gloves if they become heavily contaminated with blood or body fluids. Leave any intravenous lines or endotracheal tubes that may be present in place. Avoid washing or cleaning the body. After wrapping, the body should be immediately placed in a leak-proof plastic bag not less than 150 μm thick and zippered closed The bagged body should then be placed in another leak-proof plastic bag not less than 150 μm thick and zippered closed before being transported to the morgue.
  • Surface decontamination: Prior to transport to the morgue, perform surface decontamination of the corpse-containing body bags by removing visible soil on outer bag surfaces with EPA-registered disinfectants which can kill a wide range of viruses. Follow the product’s label instructions. the visible soil has been removed, reapply the disinfectant to the entire bag surface and allow to air dry. Following the removal of the body, the patient room should be cleaned and disinfected. Reusable equipment should be cleaned and disinfected according to standard procedures. For more information on environmental infection control, please refer to “Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus "
  • Individuals driving or riding in a vehicle carrying human remains: PPE is not required for individuals driving or riding in a vehicle carrying human remains, provided that drivers or riders will not be handling the remains of a suspected or confirmed case of Ebola, and the remains are safely contained and the body bag is disinfected as described above.

Mortuary Care

  • Do not perform embalming. The risks of occupational exposure to Ebola virus while embalming outweighs its advantages; therefore, bodies infected with Ebola virus should not be embalmed.
  • Do not open the body bags.
  • Do not remove remains from the body bags. Bagged bodies should be placed directly into a hermetically sealed casket.
  • Mortuary care personnel should wear PPE listed above (surgical scrub suit, surgical cap, impervious gown with full sleeve coverage, eye protection (e.g., face shield, goggles), facemask, shoe covers, and double surgical gloves) when handling the bagged remains.
  • In the event of leakage of fluids from the body bag, thoroughly clean and decontaminate areas of the environment with EPA-registered disinfectants which can kill a broad range of viruses in accordance with label instructions. Reusable equipment should be cleaned and disinfected according to standard procedures. For more information on environmental infection control, please refer to “Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus "

 

Disposition of Remains

  • Remains should be cremated or buried promptly in a hermetically sealed casket.
  • Once the bagged body is placed in the sealed casket, no additional cleaning is needed unless leakage has occurred.
  • No PPE is needed when handling the cremated remains or the hermetically sealed closed casket.

Transportation of human remains

  • Transportation of remains that contain Ebola virus should be minimized to the extent possible.
  • All transportation, including local transport, for example, for mortuary care or burial, should be coordinated with relevant local and state authorities in advance.
  • Interstate transport should be coordinated with CDC by calling the Emergency Operations Center at 770-488-7100. The mode of transportation (i.e., airline or ground transport), must be considered carefully, taking into account distance and the most expeditious route. If shipping by air is needed, the remains must be labeled as dangerous goods in accordance with Department of Transportation regulations (49 Code of Federal Regulations 173.196).
  • Transportation of remains that contain Ebola virus outside the United States would need to comply with the regulations of the country of destination, and should be coordinated in advance with relevant authorities.

References

CDC. Medical Examiners, Coroners, and Biologic Terrorism A Guidebook for Surveillance and Case Management. MMWR 2004;53(RR08);1-27. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5308a1.htm

Content sources:

The above article was originaly posted on the CDC website on Wednesday, October 8th, 2014.

 

 

WHO Suggests Ebola Precautions

Posted: August 7, 2014

http://nfda.org/additional-tools-embalming/4004-who-suggests-ebola-precautions.html

With news of the Ebola outbreak in West Africa generating headlines worldwide, many healthcare organizations have looked at their preparedness in the event of an outbreak in the United States.

John H. Fitch Jr. and Lesley Witter of the National Funeral Directors Association's Advocacy Division met at the Centers for Disease Control on Ebola guidance for hospitals and hospital workers in treating infected patients. "As always, we brought up the issue of infected dead bodies and what specific guidance there was for funeral directors," Fitch said. "We were actually supported by several hospital representatives and doctors since they also wanted to know how to handle the deceased if they died in the hospital."

"We not only raised the issues related to prep room protocols and whether to embalm or not, but also whether an open-casket viewing could or should be held and whether the body can be buried or must it be cremated," Fitch added. "The CDC said it was in the process of developing that guidance and would advise us when it was available."

In the meantime, the World Health Organization has called attention to a document issued in 2008 offering interim infection control recommendations for patients with suspected or confirmed diagnoses of filovirus haemorrhagic fever (HF), including Ebola or Marburg haemorrhagic feversebola. In the WHO's Interim Infection Control Recommendations for Care of Patients With Suspected or Confirmed Filovirus (Ebola, Marburg) Haemorrhagic Fever, it is recommended that the handling of human remains be kept to a minimum. Further, WHO said remains should not be sprayed, washed or embalmed. WHO also noted that personnel handling remains should wear personal protective equipment (gloves, gowns, apron, surgical masks and eye protection) and closed shoes.

Protective equipment is not required for individuals driving or riding in a vehicle to collect human remains, WHO suggests. However, protective equipment should be put on at the site of collection of human remains and worn during the process of collection and placement in a body bag. WHO advised that protective equipment should be removed immediately after remains have been placed in a body bag and then placed inside a coffin, and remains should be wrapped in sealed, leak-proof material and buried promptly.

Application of disinfectants should be preceded by cleaning. WHO recommends:

  • Do not spray (i.e., fog) occupied or unoccupied clinical areas with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit.
  • Wear gloves, gown and closed shoes when cleaning the environment and handling infectious waste. Cleaning heavily soiled surfaces increases the risk of splashes. On these occasions, facial protection should be worn in addition to gloves, gown and closed, resistant shoes.
  • Soiled linen should be placed in clearly labeled, leak-proof bags or buckets at the site of use and the container surfaces should be disinfected (using an effective disinfectant) before removal from the site. Linen should be transported directly to the laundry area and laundered promptly with water and detergent. For low-temperature laundering, wash linen with detergent and water, rinse and then soak in 0.05 percent chlorine for approximately 30 minutes. Linen should then be dried according to routine standards and procedures.
  • Linen that has been used by HF patients can be heavily contaminated with body fluids (e.g., blood, vomit) and splashes may result during handling. When handling soiled linen from HF patients, use gloves, gown, closed shoes and facial protection.
  • If safe cleaning and disinfection of heavily soiled linen is not possible or reliable, it may be prudent to burn the linen to avoid any unnecessary risks to individuals handling these items.

For post-mortem examinations, HF patient remains should be limited to essential evaluations only, and those evaluations should be performed by trained personnel. Personnel examining remains should wear eye protection, mask, gloves and gowns as recommended for patient care.

In addition, WHO recommends that personnel performing autopsies of known or suspected HF patients should wear a particulate respirator and eye protection or face shield, or a powered air purifying respirator.

WHO also recommends:

  • When removing protective equipment, avoid any contact between soiled gloves or equipment and the face (i.e., eyes, nose or mouth).
  • Hand hygiene should be performed immediately following the removal of protective equipment used during post-mortem examination and that may have come into contact with potentially contaminated surfaces.
  • Place specimens in clearly labeled, non-glass, leak-proof containers and deliver directly to designated specimen handling areas.
  • All external surfaces of specimen containers should be thoroughly disinfected (using an effective disinfectant) prior to transport.
  • Tissue or body fluids for disposal should be carefully placed in clearly marked, sealed containers for incineration.

Source: Interim Infection Control Recommendations for Care of Patients With Suspected or Confirmed Filovirus (Ebola, Marburg) Haemorrhagic Fever by the World Health Organization

(http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/ )

This article above originally appeared in the August 7, 2014, issue of the Memorial Business Journal.

 

Additional information may be found at the following links:

Ebola: Protective measures for medical staff

 

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