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WHAT’S INSIDE
Chapter 1: Infectious Disease Control for Funeral Professionals
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[4 CE hours] Professionals in the funeral industry must have knowledge concerning different types of infectious disease, their modes of transmission, and the virulence that make them dangerous and difficult to contain. This basic-level course provides specific references for downloading guidelines and training resources from the CDC, OSHA, and the WHO and includes information on infectious diseases that rise to the level of serious public health concern.
Chapter 2: Understanding Mental Health and Funerals
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[1 CE hour] In this course, the student will learn the steps intended to support funeral directors who care for the mental health needs of the bereaving family and friends as they plan the loved one’s memorial.
Final Examination Answer Sheet
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©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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FUNERAL CONTINUING EDUCATION 2024
Book code: FGA0524
FREQUENTLY ASKED QUESTIONS What are the requirements for license renewal? Licenses Expire CE Hours
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10 (5 hours are allowed through home-study)
Renewals are due on March 31st (even years)
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Chapter 1: Infectious Disease Control for Funeral Professionals
Chapter 2: Understanding Mental Health and Funerals
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How do I complete this course and receive my certificate of completion? See the inside front cover for step by step instructions to complete and receive your certificate. Are you a Georgia board-approved provider? Colibri Healthcare, LLC’s courses are approved by the Georgia State Board of Funeral Service. Are my hours reported to the Georgia board? No, the Georgia State Board of Funeral Service requires licensees to certify at the time of renewal that they have complied with the continuing education requirements. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Funeral you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.
Licensing board contact information: Georgia State Board of Funeral Service 214 State Capitol I Atlanta, GA 30334 I Phone: 404-424-9966 I Fax: (866) 888-8026 Website: https://sos.ga.gov/georgia-state-board-funeral-service
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Book code: FGA0524
FUNERAL CONTINUING EDUCATION 2024
Chapter 1: Infectious Disease Control for Funeral Professionals 4 CE Hours
By: Staff Writers Learning objectives
● Describe five CDC universal precautions for infection prevention and control for airborne, droplet, and contact transmission of pathogens. ● List five steps for personal protective equipment (PPE) compliance from the CDC guidelines for infection prevention and control procedures in the funeral home setting. Explain how pathogenic organisms may be spread in funeral home settings and identify factors that influence exposure and transmission. ● Identify five types of infectious disease that require the use of barriers, personal protective equipment, and control strategies to protect personnel from pathogens according to CDC and WHO guidelines. ● Define epidemiologically important organisms and discuss four types, including modes of transmission. ● List and discuss OSHA guidelines and strategies, including cleaning, sterilization, chemical disinfection, and barriers to protect personnel and the public from infectious disease. Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing Introduction Funeral directors in the 1980s faced new concerns related to containment of infectious disease pathogens due to the number of casualties from the HIV/AIDs virus. Funeral directors and staff were asked to deliver postmortem services for premature deaths of HIV/AIDS victims of all ages. In addition to assisting grieving families, funeral service professionals had to address serious health risks and fears surrounding embalming, funeral services, and burial of victims with the contagious disease. The demand for infection control for postmortem care of HIV/AIDS victims resulted in a detailed review and modernization of procedures for the first time in more than a century. Misinformation, fear, and hysteria led to myths of environmental contamination, which spread throughout the funeral industry. Many directors and embalmers refused to offer services to HIV/AIDS victims during this time. To address these concerns, the Centers for Disease Control (now the Centers for Disease Control and Prevention [CDC, 1992]; CDC), the World Health Organization (WHO), and the Occupational Health and Safety Administration (OSHA) developed detailed, extensive, uniform procedures to contain infectious pathogens in the healthcare field. These precautions were extended and refined for the practice of mortuary science and all areas of funeral services. Guidelines created by the CDC, and adopted by OSHA in 1991, were called “universal precautions,” which provided standardized procedures for postmortem services. Robert Mayer, author of embalming
● Describe CDC guidelines for barriers, protective equipment, and control procedures for personnel to prevent exposure to infectious material during the embalming process. ● Define CDC and OSHA guidelines for handling, cleaning, disinfection, sterilization, and waste disposal procedures during postmortem procedures to prevent disease transmission. ● Discuss the professional funeral director and embalmer’s responsibility for maintaining a safe environment for personnel, the public, and the environment. ● Identify strategies and procedures for preventing transmission and controlling Ebola and HIV/AIDS virus during all postmortem procedures. ● Select five myths concerning infectious disease contamination from embalming and burial and discuss facts from PAHO and WHO research studies that dispel them. implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics. textbooks, explained that using universal precautions means an embalmer will “treat all human remains as if they were infected with HIV, hepatitis B (HBV) or other pathogens. In other words, the embalmers should treat all bodies with the same caution that would be applied for extremely hazardous, potentially fatal infections” (Mayer, 2012). Changes in handling the body were implemented, and different postmortem technologies in all levels of thought and practices were developed and deployed by the American funeral industry (Kennedy & Nisbett, 2015). New procedures for health, safety, and training for funeral personnel helped ease fears and build confidence surrounding postmortem care of victims of infectious disease. In 2014, mortuary science encountered the Ebola epidemic, leading to a complete transformation in postmortem care to protect personnel and the public from exposure to deadly pathogens. The CDC, OSHA, and the WHO revolutionized infection control and prevention procedures, from transport to and from the hospital to burial or cremation. Some myths have persisted concerning the potential environmental contamination related to the burial of victims of infectious, communicable diseases. Misinformation and anxiety grew due to public fear over media reports of the spread of prion diseases such as bovine spongiform encephalopathy (BSE), more commonly known as mad cow disease; the human variant
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Creutzfeldt-Jakob Disease (CJD); and transmissible spongiform encephalopathy (TSE). This course will address the facts and detail the CDC, WHO, and OSHA standards and guidelines to address procedures to contain these diseases during all phases of mortuary practice. The National Funeral Directors Association (NFDA) is the guiding funeral service association, with more than 20,000 individual members and serving over 11,000 funeral homes in the United States and fifty countries (NFDA, 2022). The NFDA offers resources and materials to assist members to comply with federal, state, and county laws along with conducting and funding research on topics of health, safety, environmental, and consumer concerns. During the height of the COVID-19 pandemic, the NFDA maintained an information hub to help funeral directors with concerns about the acquisition of personal protective equipment (PPE) and about the prioritizing of funeral personnel for the newly developed vaccines. The organization made clear that they were not suggesting that vaccinations should be mandatory, merely that funeral directors, by the very nature of their work, were in greater danger from the disease than members of the general public and should be prioritized for the vaccines (NFDA, 2020, 2021). Guidance concerning the postmortem handling of COVID-19 patients evolves as more is learned about the disease, how it spreads, and whether a body can harbor the virus after death (OSHA, n.d.a). Valkenburg and colleagues (2021) state succinctly that “the infectivity of severe acute respiratory syndrome coronavirus 2 [COVID-19] in deceased persons and organisms remains unclear.” They conclude, however, that with proper biosafety precautions and personal protective equipment, “the burial or cremation process is unlikely to spread disease.” One document, most recently updated in April of 2020, addresses the emotional difficulty experienced by mortuary and death care workers having to deal with the onslaught of COVID-19 deaths (U.S. Department of Health and Human Services, 2020). Transmission of infectious agents in healthcare settings The CDC, WHO, and OSHA organizations include mortuaries, funeral homes, cemeteries, and crematory settings under the classification of health care when issuing regulations and guidelines for universal precautions. Some documents contain specific information for practitioners dealing with postmortem Definitions ● Alkaline hydrolysis – an alternative to flame cremation that uses water and alkaline under high temperatures and pressure. ● Colonization – development of a bacterial infection, though the infected person may or may not have signs or symptoms of infection. ● Diathesis – predisposition or susceptibility to suffer from a disease. ● Enveloped virus – the outermost shell is made of proteins and lipids. SARS-CoV-2, which causes COVID-19, is an enveloped virus (CDC, 2021d). ● Non-enveloped virus – contain a capsid coat made of protein, are more virulent, and can retain infectivity even after drying. ● Fomites – objects or materials, such as dishes, utensils, or clothing, that may carry infection and lead to transmission of disease. ● Flora – microorganisms such as bacteria or fungi that live in or on the body. ● Immunity – the host’s ability to resist the pathogens that cause disease. Factors related to immunity include the following:
John Erik Troyer is a leading author and researcher addressing the social and technological control of the dead body, including legal, scientific, and medical protocols and aesthetics. Troyer cautions that people addressing the issues of infectious disease in mortuary services; “need a dose of humility and effective approaches at household, community, societal and global levels. At the household level, we need to promote family-centered interactions and interventions. Cultural practices such as embalming, burial, and caregiving are family-based as well as community-based activities.”(Troyer, 2010) Professionals in the funeral industry must have knowledge concerning different types of infectious disease, their modes of transmission, and the virulence that make them dangerous and difficult to contain. The global nature of travel today leads to the rapid spread of contagious disease throughout the world. Certain diseases are not endemic to the United States; however, they can easily cross borders before they are observed or diagnosed. Individuals can carry colonies of disease and be non-symptomatic for weeks or even months as they spread disease to those they contact at home, work, or throughout their community. This course includes information on infectious diseases that rise to the level of serious public health concern. Major health organizations of the federal, state, and county epidemiology departments would be aware of the presence of individuals with serious infectious disease from the moment they were identified at the point of entry to the U.S. These agencies have jurisdiction in these cases, though in many states, if the person dies, the body would be released to the local funeral home. At this point, the director could refuse the case or the local health agency would assist them if they chose to proceed. This course provides specific references for downloading guidelines and training resources from the CDC, OSHA, and the WHO for further information. Individual states may have additional regulations and guidelines that must be reviewed on the state government website. Information is included for the control of infectious disease encountered during mortuary services to ensure the safety of personnel, funeral attendees, the general public, and the environment. procedures for preparation at the hospital, cleaning, sterilization, transport, embalming, waste disposal, viewing, burial, or cremation. Some highly contagious, drug-resistant diseases require specific regulations for postmortem care, and current regulations are included in this course. ○ The immune state at the time of exposure to an infectious agent. ○ Interaction between pathogens. ○ Virulence factors of the pathogen. ○ Host factors, such as age, and underlying disease, such as diabetes, HIV/AIDS, malignancy, transplants, or other chronic illness. ○ Medications that alter normal flora such as antimicrobial agents, gastric acid suppressors, corticosteroids, anti-rejection drugs, antineoplastic agents, and immunosuppressive drugs. ● Infection – invasion and multiplication of pathogenic microorganisms in the body. Pathogens invade the body and may lead to infection or disease that disrupts the functioning of the body. Pathogenic microorganisms are found particularly in the respiratory and gastrointestinal tracts but may live anywhere in or on the body. ● Infectious agents – four main classes: bacteria, viruses, fungi, and parasites, transmitted primarily from human sources but also inanimate environmental sources as well. ● Lumina – the inner open space or cavity of a tubular organ or cell, such as in a blood vessel or an intestine.
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● Pathogens – agents that cause infection or disease, including microorganisms such as a bacterium, protozoan, prion, or virus. These agents cause communicable diseases that spread easily through contact with others. ● Percutaneous exposure – caused by an injury, such as a needle stick or cut with a sharp object that allows contact of mucous membrane or nonintact skin with blood, saliva, tissue, or other body fluids that are potentially infectious. Injury can also occur through exposed skin that is chapped, abraded, or broken due to dermatitis or other skin conditions. CDC guidelines: Types of infectious disease and transmission Infection transmitted between an infectious agent and a host may cause disease to develop and progress, bringing about illness or death. In some cases, the host may be temporarily or permanently colonized but show no symptoms of the infection or disease. It is possible for infection to develop from colonization and rapidly progress to disease after exposure or after an extended period of colonization. Sources of infection after death The four main sources of infection that may be present in human remains include the following: ● Blood and body fluids, including saliva and lung and gastrointestinal fluids. ● Waste products, such as feces and urine. Transmission Transmission of infectious agents within a healthcare setting requires three elements: ● A source or reservoir of infectious agents. ● A susceptible host with a portal of entry to receive the infectious agent. ● A mode of transmission for the infectious agent. Individual microorganisms normally have a specific mode of transmission and route to enter the body, but some types of infection can spread in multiple ways, such as: ● Contaminated hands, fingers, or objects placed into the mouth, nose, or eyes. ● Instruments or equipment that are inadequately cleaned between patients or before disinfection or sterilization or that have manufacturing defects that interfere with the effectiveness of reprocessing may transmit bacterial and viral pathogens. ● Clothing, uniforms, laboratory coats, or personal protective equipment (PPE) may become contaminated with potential pathogens after contact with colonized or infectious agents, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), and Clostiridium difficile (C. diff.). Soiled garments have the potential to transmit infectious agents. ● Inhalation of small droplets of microorganisms can occur without PPE. ● Blood and body fluids may splash into the eye, nose, or mouth for contact with other mucous membranes. ● Breaks in the skin may lead to direct contact with microorganisms or contaminated objects. ● Pathogens may enter through any puncture or injury to the skin such as contaminated needles or sharp objects. According to OSHA guidelines (n.d.b), the routes of infectious disease transmission for mortuary personnel include contact, droplet, and airborne. ● Contact transmission can be classified as direct or indirect contact. Direct contact transmission involves transfer of infectious agents to a susceptible individual through physical contact with an infected individual such as direct skin-to-skin contact. Indirect contact transmission occurs when infectious agents transfer to a susceptible individual when the individual makes physical contact with contaminated items and surfaces, such as doorknobs, instruments, equipment, or
● Prions – proteins that can trigger other proteins to fold abmormally (Johns Hopkins Medicine, (2022). They can cause degenerative brain diseases, including mad cow disease (bovine spongiform encephalopathy, BSE), Creutzfeldt-Jakob disease (CJD), and inherited forms of dementia such as Gerstmann-Straussler-Scheinker (GSS) disease.. ● Susceptible host – an individual without adequate immunity to withstand exposure or contact with a particular infectious agent. ● Virulence – the ability of an agent of infection to produce disease. The virulence of a microorganism is a measure of the severity of the disease it causes. Exposure to a variety of infectious disease agents may occur when handling any deceased body. The body may remain infectious, and microbes may continue to colonize after death and be dispersed through contact. If infectious disease was present at the time of death, mortuary personnel, family, and the public may be at risk for infection, and burial practices involving touching and washing the body should be avoided, depending upon the type of infection present. ● Aerosols of infectious material might be released when moving or opening the body. ● Microbes may be present on the skin and spread through direct contact. examination tables. Two examples of contact-transmissible infectious agents include MRSA and VRE. ● Droplets containing infectious agents can spread during certain postmortem preparations, including transport and embalming procedures. Transmission occurs when droplets come into direct contact with the mucosal surfaces of the eyes, nose, or mouth of a susceptible individual. The distance droplets travel depends on the velocity and means by which respiratory droplets are propelled from the source, the density of respiratory secretions, environmental factors such as temperature and humidity, and the ability of the pathogen to remain infectious over that distance. A distance of three feet around the patient is an example of “a short distance from a patient” but should not be used as the sole criterion for deciding when a mask should be donned to protect from droplet exposure. Due to the variables that affect droplet transmission, staff should wear a mask when they are within six to ten feet of the body upon entry into the room, especially when exposure to emerging or highly virulent pathogens is possible. According to Harriman and Brosseau (2011), “observations of particle dynamics have shown that a range of droplet sizes, including those with diameters of thirty μm (30 micrometers, or 30 millionths of a meter) or greater can remain suspended in the air.” ● Airborne transmission occurs through very small particles or droplet nuclei that contain infectious agents and remain suspended in the air for extended periods of time. COVID-19, for example, spreads through both droplets and particles (CDC, 2022a). The U.S. Environmental Protection Agency (EPA, 2021) calculates that the particles can linger in the air for hours. When the susceptible individual inhales the pathogen, it enters the respiratory tract and can cause infection. Airborne transmission only occurs with infectious agents that are capable of surviving and remaining infectious for relatively long periods of time in airborne particles or droplet nuclei. Airborne microorganisms may be dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face-to-face contact with or been in the same room as the infectious individual. Preventing the spread of pathogens by airborne routes requires the use of special air handling and ventilation
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systems, such as an Airborne Infection Isolation Room (AIIR), to contain and safely remove the infectious agent. OSHA standards and directives for protection against transmission of infectious agents must be included in training for all personnel. These include OSHA’s bloodborne pathogens standard (29 CFR 1910.1030), which provides protection of workers from exposures to blood and body fluids that may contain bloodborne infectious agents; personal protective equipment standard (29 CFR 1910.132) and respiratory protection standard (29 CFR 1910.134), which provide protection for workers when exposed to contact, droplet, and airborne transmissible infectious agents; and TB compliance directive (CPL 02-02-078), which enforces procedures and scheduling Epidemiologically important organisms Infectious agents of particular interest for healthcare settings are called epidemiologically important organisms and are targeted for advanced methods of infection control. An “epidemiologically important organism” is identified by the following characteristics: ● Increased potential for transmission within healthcare facilities based on published reports and the occurrence of temporal or geographic clusters of more than two patients (CDC, 2019a). A single case of healthcare-associated invasive disease caused by certain pathogens is generally considered a trigger for investigation and enhanced control measures because of the risk of additional cases and severity of illness associated with these infections. ● Antimicrobial resistance to first-line therapies. Multidrug-resistant organisms (MDROs) MDROs are microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents. These pathogens are usually resistant to all but a few commercially available antimicrobial agents, so MDROs are considered to be epidemiologically important and deserve special attention in mortuary facilities. MDROs are transmitted by the same routes as other infectious agents. Preventing the emergence and transmission of these pathogens requires a comprehensive approach that includes administrative involvement, education and training of personnel, comprehensive surveillance for targeted MDROs, application of infection control precautions, and environmental measures such as cleaning and disinfection of the environment and equipment. MDROs include: ● Clostridium difficile (C. diff). ● Carbapenem-resistant Enterobacteriaceae (CRE). Agents of bioterrorism The CDC has designated agents that cause anthrax, smallpox, plague, tularemia, viral hemorrhagic fevers, and botulism as Category A, high priority, because these agents can be easily dispersed environmentally, through food, water, air, and/or transmitted from person to person; can cause high mortality and have the potential for major public health impact; and might cause public panic and social disruption. The federal government categorizes bioterrorism agents into A (the highest priority), B, and C. These agents identified by the CDC (2018) include the following:
for occupational exposure to tuberculosis (TB). In some cases, where a specific OSHA standard does not apply, the General Duty Clause (Sec. 5(a)(1) of the Occupational Safety and Health Act requires employers to furnish to each employee a place of employment free from recognized hazards that are causing or are likely to cause death or serious physical harm to their employees. Each employer must comply with occupational safety and health standards under this Act. In addition, each employee must comply with occupational safety and health standards and all rules, regulations, and orders issued pursuant to this Act, which are applicable to his own actions and conduct (OSHA, n.d.c). ● Common and uncommon microorganisms with unusual patterns of resistance. ● Difficult to treat because of resistance to multiple classes of antimicrobial agents. ● Association with serious clinical disease, increased morbidity, and mortality. ● A newly discovered or reemerging pathogen.. These epidemiologically important organisms include C. difficile , bioterrorism agents (such as anthrax), prion diseases, SARS-CoV, SARS-CoV-2 (COVID-19), monkeypox, and noroviruses, as well as hemorrhagic fever viruses (including Ebola, Marburg, Lassa, and Crimean-Congo hemorrhagic fever viruses), and multi-drug resistant organisms. The CDC updated its research on modes of transmission and effective preventive measures in 2019, and these updates are included in this course. ● Drug-resistant Campylobacter . ● Fluconazole-resistant Candida . ● Extended spectrum beta-lactamase (ESBL) producing organisms. ● Vancomycin-resistant Enterococci (VRE). ● Multidrug-resistant Pseudomonas aeruginosa . ● Drug-resistant non-typhoidal Salmonella . ● Drug-resistant Salmonella serotype Typhi. ● Drug-resistant Shigella . ● Methicillin-resistant Staphylococcus aureus (MRSA). ● Drug-resistant Streptococcus pneumoniae . ● Drug-resistant tuberculosis. ● Vancomycin-resistant Staphylococcus aureus . ● Erythromycin-resistant Group A Streptococcus . ● Clindamycin-resistant Group B Streptococcus . Category B ● Brucellosis. ● Epsilon toxin of Clostridium perfringens. ● Food safety threats such as Salmonella species, Shigella , and E. coli O157:H7. ● Glanders (primarily a disease of horses but used as a biological weapon in both World Wars; Pal & Gutama, 2022). ● Melioidosis. ● Psittacosis. ● Q fever. ● Typhus fever. ● Various types of viral encephalitis. Category C ● Emerging infectious diseases such as Nipah virus and hantavirus. ● Neisseria gonorrhoeae. ● Multidrug-resistant Acinetobacter .
Category A ● Anthrax. ● Botulism. ● Plague.
● Smallpox. ● Tularemia. ● Viral hemorrhagic fevers (including Filoviruses such as Ebola and Marburg fever and Arenaviruses such as Lassa and Machupo fever).
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Prions The CDC defines transmissible spongiform encephalopathies (TSEs) as a family of rare, progressive neurodegenerative disorders that affect both humans and animals. They are distinguished by long incubation periods and characteristic spongiform changes associated with neuronal loss. The causative agents of TSEs are believed to be prions. The term “prions” refers to “abnormal, pathogenic agents that are transmissible and are able to induce abnormal folding of specific normal cellular proteins called prion proteins that are found most abundantly in the brain” (CDC, 2021c). The functions of normal Identified prion diseases in humans Creutzfeldt-Jakob disease (CJD) is a rapidly progressive, degenerative, neurologic disorder of humans caused by a transmissible prion. The incubation period between exposure and onset of symptoms varies from two years to many decades, though death occurs within one year of the onset of symptoms. Most CJD cases occur sporadically, with no known environmental source, and ten percent are familial. Some iatrogenic transmission has occurred, most notably through corneal transplants (CDC, 2021a). Variant CJD (vCJD) is not the same disease as classic CJD. It has different clinical and pathologic characteristics from classic CJD. Each disease also has a particular genetic profile of the prion protein gene. Variant Creutzfeldt-Jakob disease (vCJD) Severe acute respiratory syndrome (SARS) SARS is a respiratory disease that emerged in China late in 2002 and spread to several countries including Mainland China, Hong Kong, Hanoi, Singapore, and Toronto. There have been cases of laboratory evidence of SARS in the U.S. but no deaths have occurred. SARS outbreaks have occurred in healthcare settings and transmitted to large numbers of healthcare personnel and patients with evidence of droplet, contact transmission, Monkey pox Monkeypox, a rare viral disease found mostly in rainforest countries of Central and West Africa, made a brief appearance in the United States in 2003, and was traced to captive prairie dogs that had been in contact with exotic animals (CDC, 2019a). The disease made another appearance in the United States, and around the world, in 2022 (CDC, 2022b). Monkeypox is caused Norovirus Noroviruses, formerly referred to as Norwalk-like viruses, are members of the Caliciviridae family. Environmental contamination has been documented as a factor in transmission during outbreaks of this highly contagious disease. Widespread, persistent, and undetected contamination of the environment and fomites can make outbreaks extremely difficult to control. Clinical observations and detection of norovirus DNA on surfaces Hemorrhagic fever viruses (HFV) The hemorrhagic fever viruses are a mixed group of viruses that cause serious disease with high fever, skin rash, bleeding diathesis, and high mortality; the disease caused by the viruses is referred to as viral hemorrhagic fever (VHF). Commonly known HFVs are Ebola and Marburg viruses (Filoviridae); Lassa virus (Arenaviridae); Crimean-Congo hemorrhagic fever and Rift Valley fever viruses, or Bunyaviridae; and dengue and yellow fever viruses, or Flaviviridae (CDC, 2019a). Person-to-person transmission is mainly due to direct blood and body fluid contact. Percutaneous exposure to contaminated blood carries a high risk for transmission and increased mortality during the embalming process. Large numbers of Ebola viral
prion proteins are still not completely understood, but the abnormal folding of the prion proteins leads to brain damage and the characteristic signs and symptoms of the disease. Prion diseases are usually rapidly progressive and always fatal. Prion diseases in animals include scrapie in sheep and goats; bovine spongiform encephalopathy (BSE), or “mad cow disease,” in cattle; and chronic wasting disease in deer and elk. BSE, first recognized in the United Kingdom (UK) in 1986, was associated with a major epidemic among cattle that had consumed contaminated meat and bone meal. is a prion disease that was first described in 1996 in the United Kingdom. There is now strong scientific evidence that the agent responsible for the outbreak of prion disease in cows, BSE, is the same agent responsible for the outbreak of vCJD in humans (CDC, 2022c). Although most cases of vCJD have been reported from the UK, cases also have been reported from other parts of Europe, Japan, Canada, and the United States. Healthcare workers use standard precautions when caring for patients with CJD and vCJD. Postmortem handling of these patients will be discussed later in the course. and airborne transmission. The CDC recommends universal precautions, with emphasis on hand hygiene, and contact precautions with emphasis on environmental cleaning, because SARS CoV RNA has been identified on surfaces in the rooms of SARS patients. Airborne precautions, including use of fit- tested NIOSH-approved N95 or higher level respirators, and eye protection are also indicated. by an orthopoxvirus that is similar in appearance to smallpox but causes a milder disease. Transmission from infected animals and humans occurs primarily through direct contact with lesions and respiratory secretions, but airborne transmission from animals to humans, though unlikely, cannot be excluded (CDC, 2019a). five feet above levels normally touched suggest that aerosolized particles may travel distances beyond three feet. Individuals who are responsible for cleaning the environment may be at increased risk of infection. The virus is resistant to many cleaning and disinfection agents and may survive in ten parts per million (ppm or one milligram per liter) or less of chlorine (CDC, 2019a). particles can be found in the skin and the lumina of sweat glands, which indicates that transmission could occur from direct contact with intact skin. Evidence to support direct transmission from intact skin is limited, but postmortem handling of infected bodies is an important risk for transmission. There have been situations where transmission occurred among individuals with no direct contact. In these rare cases, there is speculation that airborne transmission could have occurred. Airborne transmission of HFVs in humans has not been scientifically observed, though the possibility of airborne transmission exists and the CDC has not been able to completely exclude droplet or indirect contact transmission.
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CONTAINING THE EBOLA AND HIV/AIDS VIRUS
World Health Organization 2014 Ebola precautions for funeral directors The Ebola epidemic spread to American health workers overseas and prompted the CDC and the WHO to develop standards, preparedness regulations, and guidelines to address treatment and prevention in the U.S. (CDC, 2015; NFDA, 2014). Cleaning should precede application of disinfectants. 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
avoid any unnecessary risks to individuals handling these items. For postmortem examinations, hemorrhagic fever patient remains should be limited to essential evaluations only, and trained personnel should perform those evaluations. 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 hemorrhagic fever 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 postmortem examination and that may have come into contact with potentially contaminated surfaces. period after death. In addition, the study revealed that viral RNA was detectable for ten weeks (Prescott et al., 2015). The CDC published the following guidelines in 2015 to protect against the postmortem spread of Ebola infection at the site of death, prior to transport, during transport, at the mortuary, and during final disposition of remains. The guide should be followed to train staff in the safe handling of human remains that may contain Ebola virus by properly using PPE and following decontamination measures at every step of the process. blood, urine, saliva, feces, or vomit to unprotected mucosa such as eyes, nose, or mouth during postmortem care. In addition to federal laws and guidelines that apply to mortuary workers contained in this course, mortuary practices and workers may also be subject to state, tribal, territorial, and local regulations. Staff should always consult local health department officials for additional guidance on laws that affect mortuary practices. The CDC recommends that licensed funeral directors, who have agreed to accept the bagged remains, work in close collaboration with public health officials in their state or local jurisdiction to safely implement each step of the process. ● Do not remove any inserted medical equipment from the body, such as intravenous (IV) lines, endotracheal or other tubing, or implanted electronic medical devices. ● Cremate the body. If cremation cannot be done because of safety concerns, the body should be buried in a standard metal casket or other comparable burial method.
soiled surfaces increases the risk of splashes. On these occasions, staff should wear facial protection 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 linens with detergent and water, rinse, and then soak in 0.05 percent chlorine for approximately thirty minutes. Linen should then be dried according to routine standards and procedures. When handling soiled linen from hemorrhagic fever 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 linens to Human-to-human transmission is the principal feature in Ebola virus outbreaks; the virus is transmitted from symptomatic persons or contaminated corpses or by contact with objects acting as fomites. Contact with corpses during mourning and funeral practices, which can include bathing the body and rinsing family members with the water, or during the removal and transportation of bodies by burial teams has resulted in numerous infections. A study published by the CDC on the postmortem stability of the Ebola virus shows that it can persist for more than seven days on surfaces of bodies, confirming that transmission from deceased persons is possible for an extended Background Given the systems currently in place to identify people with Ebola virus disease (EVD), beginning with screening and interception at airports for passengers from countries with known outbreaks, Ebola-related deaths in the United States would likely occur within a hospital setting, and all Ebola cases are immediately reported to and monitored by the CDC and state and local health agencies. Ebola can be detected throughout the bodies of patients who die of the disease. Ebola can be transmitted in postmortem care by laceration and puncture with contaminated instruments; through direct handling of human remains without recommended PPE; and through splashes of Key points ● Ebola virus can be transmitted in postmortem care settings through unsafe handling of remains. ● Only personnel trained in handling infected human remains and wearing recommended PPE should touch or move any human remains from a person who has died from Ebola. ● Do not wash or clean the body. ● Do not embalm the body. ● Do not perform an autopsy unless absolutely necessary. If an autopsy is necessary, consult the state health department and the CDC regarding necessary precautions.
● Place specimens in clearly labeled, non-glass, leakproof containers and deliver directly to designated specimen handling areas. ● All external surfaces of specimen containers should be thoroughly disinfected prior to transport. ● Tissue or body fluids for disposal should be carefully placed in clearly marked, sealed containers for incineration. 2015 CDC guidance for personnel: Postmortem care in U.S. hospitals and mortuaries to protect against the spread of Ebola
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Book Code: FGA0524
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Definitions of terms in the CDC guidance Contaminated area – areas that may contain Ebola virus, including the patient treatment room. Only workers wearing PPE that conforms to CDC’s Guidance on Personal Protective Equipment for Healthcare Workers are allowed in the contaminated area. Decontamination area – area directly accessible to the contaminated area. Workers will perform final decontamination in the decontamination area before passing the human remains to the clean area. Clean area – noncontaminated area used for planning and staging. Only workers who have not entered the contaminated Equipment list The following equipment should be used in the contaminated area: ● A hospital gurney containing three pre-opened cremation- compatible body bags with the following specifications: ○ First bag (top layer on gurney): vinyl or other chlorine- free material, minimum of 6 mil thickness (152 micrometers). To prevent any leakage of fluids, all seams should be factory heat-sealed or welded, not sewn, and the zipper should be on top. ○ Second bag (middle layer on gurney): chlorine-free material impervious to fluids that can be heat-sealed around the body to form a leakproof body bag. This bag should be specifically designed for the containment and transport of infectious human remains. The material should be precut to provide sufficient material to envelop the body and first bag. ○ Third bag (bottom layer on gurney): laminated vinyl or other chlorine-free material, minimum of 18 mil thickness (457 micrometers), with handles that are not sewn on, such as riveted handles reinforced with handle straps that run under the pouch. To prevent any leakage of fluids, all seams should be factory heat- sealed or welded, not sewn, and the zipper should be on top. ● Thermal sealer for sealing the second bag. ● PPE recommended for personnel entering the room of a patient with EVD as described in the CDC’s Guidance on Personal Protective Equipment for Healthcare Workers. ● Scissors for cutting excess material from heat-sealed bag. Postmortem preparation in a hospital room The following points are important considerations for postmortem preparation of human remains contaminated with Ebola virus: ● Ensure that workers handling the body and the trained observer wear the recommended PPE and follow all of the procedures in the CDC’s Guidance on Personal Protective Equipment for Healthcare Workers. ● Follow the cleaning and disinfecting recommendations found in the CDC’s Guidance for Environmental Infection Control in Hospitals for Ebola Virus. According to this guidance, PPE surfaces, equipment, and patient care area surfaces
area or who have properly doffed their PPE after being in the contaminated area are permitted in the clean area. Workers put on clean PPE in the clean area under the direction of a trained observer. Cremation – the act of reducing human remains to ash by intense heat. Leakproof bag – a body bag that is puncture-resistant and sealed in a manner to contain all contents and prevent leakage of fluids during handling, transport, or shipping. ● Device capable of taking and securely transferring photographs electronically via Wi-Fi, email, or text message (such as a digital camera or mobile phone). ● EPA-registered hospital disinfectant and wipes with a label- claim for use against a nonenveloped virus. ● Alcohol-based hand rub (ABHR). ● Red biohazard bag for medical waste. ● Zip tie for locking the third bag shut at the zipper. ● Enlarged copy of the Ebola Mortuary Guidance Job Aid: Steps for Postmortem Preparation of Ebola Infected Human Remains in a Hospital and tape for posting these step-by- step guidelines to a wall in the contaminated area. The following equipment should be used in the clean area: ● Hospital gurney or mortuary stretcher. ● Adhesive-backed pouch that is applied to the decontaminated body bag. ● Single-use (disposable) gloves with extended cuffs and a long-sleeved disposable gown. ● Biohazard spill kit, including recommended PPE; absorbent materials such as paper towels, kitty litter, or a solidifier; an EPA-registered hospital disinfectant; and biohazard waste bags. ● Infectious substance labels to be applied to the decontaminated body bag, including the following: ○ Black and white “infectious substance” label. ○ United Nations (UN) 2814 label. ○ “Do not open” label. ○ Name and phone number of the hospital administrator. that become visibly soiled should be decontaminated immediately using an EPA-registered hospital disinfectant with a label claim for use against a nonenveloped virus. ● Place all waste produced during postmortem preparation and decontamination into red biohazard bags in the contaminated area, following the CDC Guidelines for Ebola- Associated Waste Management. Highlights from these CDC guidances and guidelines are included in this course. ● Use the camera or other device to take a photograph of the decedent’s face for identification purposes. The photograph should be securely transferred electronically to the pre- identified site manager. The device must be decontaminated before being removed from the contaminated area or reused. If not decontaminated, the device should be discarded along with other medical waste. ● Position the gurney with the three pre-opened body bags next to the hospital bed with the body. ● Pull the bed sheet(s) that are under the body up and around the front of the body. Do not wash or clean the body. Do not remove any inserted medical equipment such as IV lines or endotracheal or other tubing from the body. ● Remove the first bag from the gurney. Gently roll the body wrapped in sheets while sliding the first bag under the body.
CDC step-by-step guidelines for postmortem preparation in a hospital setting These step-by-step guidelines are intended to protect workers involved in the postmortem preparation of the body in a hospital setting. The size and weight of the body being prepared and the ability of the workers to lift the body and assist with managing the body bag will determine the number of workers needed for the process. For the death of an average-size adult, for example, a minimum of three healthcare workers or other workers properly trained in handling infectious bodies should assist with the
process: two to lift the body and one to hold the body bag open. CDC recommends posting an enlarged copy of the following step-by-step guidelines in the contaminated area. The workers should read the guidelines aloud as they perform each step of the procedure. ● Turn on the thermal sealer to allow it to warm up during the initial preparation of the body. This sealer will be used to seal the second body bag.
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Book Code: FGA0524
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