CURRENT INFECTION PROBLEMS FOR EMBALMERS AND FUNERAL DIRECTORS

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CURRENT INFECTION PROBLEMS FOR EMBALMERS AND
FUNERAL DIRECTORS
WHATS BUGGING YOU?
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CONTACT INFORMATION

• Fred Roberts MD, FRCPC
• Medical Director of Infection Control, Fraser
  Health Authority
• Clinical Professor Emeritus, UBC Department of
  Pathology and Laboratory Medicine.
• E- mail drfjr_at_shaw.ca

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WHERE ARE THE RISKS ?

• BODY REMOVAL AND MANIPULATION
• EMBALMING
• BODY FLUIDS
• ENVIRONMENT
• FUNERAL SERVICES
• BODY FLUID LEAKS AND HANDLING
• DECEASEDS RELATIVES

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RISKS FROM RELATIVES

• DECEASED
• INFECTED RELATIVES IN INCUBATION STAGE AT SERVICE
• FUNERAL DIRECTOR AND OTHERS AT THE SERVICE

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INCIDENCE OF INFECTIONSBeck-Sague C et al.
Universal Precautions and Mortuary Practitioners
. J Occup Med 199133874-878

• Survey in 1988 of 860 members of National Select
  Morticians. 539 responded
• 89 (17) reported infectious diseases related to
  their occupation.
• - Hepatitis 26
• - Skin infections (Staphylococcal) 27
• - Pulmonary and skin tuberculosis 16
• - Other infections mostly respiratory 9
• - Primary sepsis 5
• - Lice and Scabies 6
• 39 reported at least one needle stick injury in
  the last year.

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CONTRIBUTING FACTORS

• ATTITUDES
• PHYSICAL PLANT
• EQUIPMENT
• COST
• ORGANIZATION AND PLANNING

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CONTRIBUTING ATTITUDES

• I HAVE BEEN DOING THIS FOR 20 YEARS WITH NO
  PROBLEMS!! WHY SHOULD I CHANGE???
• THE INFECTION PROBLEMS ARE CONSTANTLY CHANGING.
  WHAT WORKED 20 YEARS AGO MAY NOT WORK TODAY.

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UNRECOGNIZED INFECTIONS

• VIRAL HEPATITIS
• HIV (AIDS)
• TUBERCULOSIS
• RESPIRATORY OUTBREAKS (SARS)
• BRUCELLOSIS
• HEMORRHAGIC FEVERS

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SOURCES OF INFECTION HAZARDS

• RESPIRATORY TRACT
• AIRBORNE
• DROPLET
• CONTACT
• SKIN
• FOMITES
• INGESTION AND INJECTION

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RESPIRATORY TRACT HAZARDS

• DROPLET RESPIRATORY SECRETION DROPLETS ARE
  LARGE AND SETTLE OUT QUICKLY. CONTAMINATION FOR 1
  METRE.
• AIRBORNE RESPIRATORY SECRETIONS DRY INTO SMALL
  DROPLET NUCLEI THAT STAY SUSPENDED IN THE AIR.
  

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TUBERCULOSIS

• Spread by inhalation of droplet nuclei
• Incidence varies yearly and with certain social
  and ethnic groups.
• Often found involving family groups
• Drug resistant strains are occurring
• A recognized risk for embalmers

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RISKS OF TB TO EMBALMERS

• Many Papers Demonstrating increased rates in
  Medical Students, Pathologists and Morgue
  Workers.
• 1998 JOEM Vol. 40 pp497-503
• 864 Funeral Home Employees
• Positive skin tests for TB (designates primary
  infection) double in those that embalm over those
  that do not.

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RISKS OF TB TO EMBALMERS

• January 2000 NEJM Vol. 342 pp.246-248
• Patient with AIDS and known TB. Stopped TB
  treatment. Died with pneumonia.
• The embalmer with 15 years experience developed
  shortness of breath and other symptoms and found
  to have TB with the same strain as the embalmed
  person.
• 2001 Chest Vol.119 pp 640-642
• In Florida a review of new TB cases found two
  similar cases to the above.

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PREVENTION OF TUBERCULOSIS

• Prevention of aerosols - equipment
• Proper ventilation
• Use of masks
• Baseline assessment at time of employment
• skin test or chest x-ray
• assessment after known exposure

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Aerosol Production

• BODY MOVEMENTS
• ROLLING AND TURNING
• ABDOMINAL COMPRESSION
• CHEST COMPRESSION

• EQUIPMENT

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AEROSOL PRODUCTION
VENTURI TYPE SUCTION
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AEROSOL PRODUCTION
To prevent water line contamination a back flow
valve is required.
Aerosols can be produced with the splashing in
the sink.
VENTURI SUCTION
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NO BACKFLOW VALVE
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MASKS FOR TB PREVENTION

• MASK SHOULD BE MARKED AS N95
• WCB REQUIRES N95 MASKS TO BE FIT TESTED
• DUCK BILL TYPE ARE MORE COMFORTABLE THAN THE HARD
  CONE TYPE

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Duck Bill Mask
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PROCEDURAL MASK
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Surgical Mask
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Hepa Filter Mask
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MASK WITH EYE SHIELD
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FACE SHIELD
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VENTILATION FOR TB PREVENTION

• FOR MORGUES THE RECOMMENDATION IS FOR 12 AIR
  EXCHANGES PER HOUR
• AIR EXHAUST MUST BE DIRECTLY TO THE OUTSIDE TO
  PREVENT SPREAD THROUGHOUT THE BUILDING. THIS MUST
  BE AWAY FROM INTAKE VENTS.
• ULTRAVIOLET LIGHTS CAN BE USED TO TREAT THE
  EXHAUSTED AIR.
• REMEMBER TO LEAVE THE VENTILATION RUNNING AFTER
  THE PROCEDURE TO CLEAR THE ROOM.

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DROPLET SPREAD

• THIS INCLUDES SARS AND SIMILAR AGENTS AND
  INFLUENZA.
• VENTILATION IS NOT A SERIOUS PROBLEM AND
  PRECAUTIONS ARE SIMILAR TO THOSE FOR CONTACT
  HAZARDS.
• GLOVES, GOWNS, MASKS, FACESHIELDS, CAPS AND BOOTS
  ARE ALL CONSIDERATIONS

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INFLUENZA

• Occurs annually between Nov and April.
• Three types - A,B, and C.
• Type A the usual epidemic strain.
• Minor changes occur from year to year (antigenic
  drift).
• Major changes (antigenic shift) occurs
  sporadically with Type A often causing a
  panepidemic.

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INFLUENZA

• Mostly Droplet spread but airborne occurs in
  crowded areas.
• Usually chest infection, cough, fever, headache,
  muscle aches for 2-7 days.
• Vaccine available against the common type A and
  B strains of the past few years.
• Vaccine must be given yearly for protection.

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MRSA

• Their importance is the limited antibiotics that
  are effective.
• Control measures aimed at preventing persons
  susceptible to infection ( burns, Surgical and
  ICU patients etc ) from exposure

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MRSA

• Risk to the embalmer no greater than with other
  staphylococci unless they have factors making
  them more susceptible to infection..
• Standard precautions are adequate for protection.

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CONTACT HAZARD PRECAUTIONS

• HAND WASHING
• PROTECTIVE DEVICES
• BARRIER TECHNIQUES
• DISINFECTION AND STERILIZATION

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PATHOGEN
PROTECTIVE NORMAL FLORA
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ARE YOUR GLOVES, GOWN OR MASK A RISK ON THE
OUTSIDE?
IF YOU TOUCH SOMETHING WITH THEM WILL IT SPREAD
THE CONTAMINATION?
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APRONS
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Fluid Resistant Gowns
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BODY SUIT
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IMPORTANCE OF WATER PROOFING
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CONTACT HAZARDS ENVIRONMENTAL CONCERNS

• DESIGATION OF CLEAN AND DIRTY AREAS
• PROPER CLEANING TECHNIQUES.

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PREP ROOM POLICY

• DOES THE ROOM HAVE DISTINCT BORDERS?
• ARE THERE BIOHAZARD WARNING SIGNS?
• ARE THERE TRAFFIC CONTROL MEASURES?
• ARE THERE ADEQUATE CLEANING, DISINFECTION AND
  STERILIZATION PRACTICES?
• ARE THERE PROPER PRACTICES FOR DISPOSAL OF
  BIOHAZARDOUS GARBAGE?
• ARE THERE WRITTEN POLICIES FOR MANAGING ACCIDENTS
  LIKE SHARPS INJURIES?
• ARE THERE POLICIES RELATED TO PANDEMICS, WORKER
  ILLNESS AND INJURY, IMMUNIZATION ETC

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HAZARDS FROM INJECTION
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AIDS

• A retrovirus spread in blood.
• Present in many body fluids -saliva etc. but does
  not seem to be infectious.
• Commonest transmissions - sex, blood transfusions
  and sharps injuries.
• Not as infectious as Hepatitis B

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VIRAL HEPATITIS

• Hepatitis is inflammation of the liver. Viruses
  only one of many different causes.
• Hepatitis viruses named as Hepatitis A - E
• Hepatitis A and E are food and water spread
• Hepatitis B,C, D are spread by blood
• Vaccines are available for only Hepatitis A and B

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VIRAL HEPATITIS

• Virus Method of Spread Persistent
  Infection Vaccine
• Hepatitis A Fecal Oral
  No Yes
• Hepatitis B Blood exposure Yes
  Yes
• Hepatitis C Blood exposure
  Yes No
• Hepatitis D Blood exposure Yes
  No
• Requires Hepatitis B to be present
• Hepatitis E Fecal-Oral
  No No

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VIRAL HEPATITIS - PREVENTION

• Immunization for Hepatitis A B
• Adherence to Standard Precautions for all
  hepatitis types
• Procedures and Practices to reduce the chance of
  sharps injuries

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PRION DISEASES

• Not one of the usual infectious agents but an
  abnormal protein.
• Different diseases in different animals.
• Except for bovine disease spread to humans from
  other animals not known.
• Several human forms with CJD the commonest.

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PRION DISEASE - CJD

• 3 types - hereditary, sporadic, variant.
• A slow progressive fatal dementia.
• Variant form may be related to bovine type
  infection.
• Spread by transfer of CNS tissue - corneal dura
  mater grafts, neurosurgical instruments.

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HERPETIC WHITLOW

• Herpes virus the same as a cold sore.
• Occurs in persons working in the mouth such as
  nurses, dentists etc.
• Caused by the inoculation of the virus into the
  skin through a puncture wound, scratch or minor
  wound.
• Lesion keeps recurring similar to a lip cold sore.

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Herpetic Whitlow
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SHOULD BE DISCARDED WHEN ¾ FULL
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• HAZARDS FROM INGESTION

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EPIDEMICS

• Outbreaks of diseases with a considerable
  mortality rate occur - SARS, Influenza,
  Hemorrhagic Fevers etc.
• In some instances the death rate may be very high
  and represent unusual risks to embalmers and
  funeral directors.
• A plan should be in place developed with Public
  Health Authorities

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SUMMARY

• Always use proper protective gear and procedures.
• Keep immunizations up to date.
• Follow disinfection and sterilization procedures
  correctly.
• Control the prep room traffic activities.
• Consider infection prevention in designing and
  renovating facilities.