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

Who this is for: Personnel who perform postmortem care in U.S. hospitals and mortuaries

What this is for: 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

How to use: To guide staff in the safe handling of human remains that may contain Ebola virus by properly using personal protective equipment and following decontamination measures at every step of the process.

Key Points

  • In patients who die of Ebola virus infection, the virus can be detected throughout the body.
  • Ebola virus can continue to be transmitted in postmortem care settings through unsafe handling of remains.
  • Handling should be kept to a minimum and only trained personnel wearing PPE should touch, or move, any Ebola-infected remains.
  • Remains should be cremated or buried promptly in a hermetically sealed casket; autopsies should be avoided.
  • Transportation of remains outside the U.S. must comply with the regulations of the country of destination, and should be coordinated in advance with relevant authorities.

This document provides guidance on the safe handling of human remains that may contain Ebola virus. These recommendations are for use by personnel who perform postmortem care in U.S. hospitals and mortuaries. In patients who die of Ebola, the 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 (PPE). It can also be transmitted through splashes of blood or other body fluids such as urine, saliva, or feces to unprotected mucosa (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.
  • Keep handling of human remains to a minimum.
  • Avoid autopsies on patients who have died of Ebola. 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.

Leak-proof 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.

Personal protective equipment for postmortem care personnel

  • Personal protective equipment (PPE): Prior to contact with the body, postmortem care personnel should wear PPE.
  • Putting on, wearing, removing, and disposing of PPE: PPE should be in place BEFORE contact with the body, worn during the process of collection and placement in body bags, and removed immediately after and discarded appropriately (Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus). Use caution when removing PPE to avoid contaminating the wearer. Hand hygiene (washing 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. A gown or gloves should be changed 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. Once 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, 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 that 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, refer to CDC's 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 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 (such as airline or ground transport), must be considered carefully, taking into account distance and the most expeditious route.
  • Although Ebola virus is a Category A infectious substance regulated by the U.S. Department of Transportation’s Hazardous Materials Regulations (HMR, 49 Code of Federal Regulations Parts 171-180), DOT has issued guidance that human remains contaminated with a Category A infectious substance are excepted from the HMR.
  • 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.

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