Posted: August 7, 2014

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 (www.who.int/csr/bioriskreduction/interim_recommendations_filovirus.pdf).