GUIDE TO INFECTION

CONTROL IN THE HOSPITAL

CHAPTER 41:

The Infection Hazards of

Human Cadavers


Authors
P.N. Hoffman, MD
T.D. Healing, MD

Chapter Editor
Shaheen Mehtar, MBBS, MRCPath, UK; FRC Path UK; FCPath (S
Africa); MD (London)

The authors would like to acknowledge the contributions of the late Dr.
Susan Young, who was fundamental to the structure and content of this
chapter and was an author on all previous editions.

Topic Outline
Key Issues
Known Facts
Controversial Issues
Suggested Practice
General Considerations
The Recently Dead
 Tuberculosis
Meningitis and Septicaemia
Gastrointestinal Pathogens
Transmissible Spongiform Encephalopathies (TSEs)
Hepatitis
HIV
Viral Haemorrhagic Fevers (VHFs)
Reduction of Risk
Post-Mortem Rooms
Preparation of the Dead for Funerals
Emergency Service Personnel
Disposal of the Dead
Suggested Practice in Under-Resourced Settings
Summary
References

Chapter last updated: February, 2018

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KEY ISSUES
Cadavers may pose hazards to those handling them. The recently dead
may have been infected by a wide range of pathogens, those presenting
particular risks include, tuberculosis, streptococcal infection, gastro-
intestinal pathogens, the agents causing transmissible spongiform
encephalopathies (e.g. Creutzfeldt-Jakob disease), hepatitis B and C, HIV
infection, Middle East respiratory syndrome (MERS), haemorrhagic fever
viruses such as Ebola, and possibly meningitis and septicaemia (especially
meningococcal). None of the organisms that caused mass death in the
past (e.g. plague, cholera, typhoid, tuberculosis, smallpox) is likely to
survive long in burials.

KNOWN FACTS
• Most of the microorganisms that cause death do not survive for long
after the host dies or are not readily transmissible in that context.
• Soft tissues remaining on a cadaver could present an infection risk.
• Long-buried bodies reduced to skeletons are not a hazard.
• A possible hazard in old burials is anthrax, which can form resistant
spores but this is unlikely.

Controversial Issues

There is a theoretical concern that smallpox may survive in buried bodies,

but the risk from minimal residual virus in dry scabs is not considered to
present a valid infectious threat. People should not be vaccinated
specifically to deal with this hazard as the risk of smallpox vaccination
greatly outweighs the infection risk.

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SUGGESTED PRACTICE

General Considerations

Whether dealing with the recently dead or with old burials, and regardless
of which infectious agents may be present, the risk of acquiring infection
can be greatly reduced by:
• Covering cuts or lesions with waterproof dressings.
• Careful cleansing of any injuries sustained during procedures.
• Good personal hygiene
• Use of appropriate protective clothing (see Table 41.1)

Most people have little to do with the dead, although they may at some
time in their lives need to deal with the cadavers of relatives or friends
during burial rituals. Some have jobs that regularly bring them into contact
with cadavers, exposing them to the risk of acquiring infections. These
include doctors (especially pathologists), nurses, mortuary attendants,
members of the emergency services, forensic scientists, embalmers,
funeral directors and religious officials or others who routinely prepare
bodies for the funeral or who perform final rites.

In most circumstances, the infected living are a much greater hazard than
are the dead, even those who have died of infectious disease. Whilst a
person is alive, invading pathogens can multiply and are readily
transmitted; the patient is a continuing source of infection. Once the host is
dead, most pathogenic microorganisms stop multiplying and die rapidly as
a result of microbial competition as the body decomposes.

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The Recently Dead

The diseases and organisms which may pose particular risks vary in
different parts of the world but include tuberculosis; streptococcal
infection; gastro-intestinal organisms; Creutzfeldt-Jakob disease; viral
hepatitis, HIV infection, MERS, and other viral infections (particularly viral
haemorrhagic fevers such as Lassa, Marburg, or Ebola); and possibly
meningitis and septicaemia (especially meningococcal) (see Table 41.2). In
general, good practice, the use of appropriate protective clothing, will
greatly reduce the risk of acquiring infection, but some additional
precautions may be advisable for particular infections, for example, when
dealing with infectious agents transmitted by a vector that is resident on
the deceased (e.g. body lice and typhus, fleas, and plague), as these will
leave the deceased and may move onto those handling the cadaver putting
them at risk.

Tuberculosis

Opening cadavers of individuals infected with tuberculosis is dangerous

and workers in morbid anatomy, pathologists, mortuary technicians, and
medical students have a comparatively high rate of tuberculin conversion.
BCG vaccination and an annual chest X-ray are advised for such
individuals. Post mortems or autopsies should be carried out with
appropriate personal protective equipment and in a negative pressure or
well ventilated room.

Meningitis and Septicaemia

Meningitis can be caused by a wide range of organisms but only

tuberculosis (see above) and meningococci are likely to present a risk.

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Septicaemia is a common terminal event and can be caused by many
different organisms (often the patient's own flora), most of which present
no hazard. Only cases of meningococcal septicaemia or of infection with
group A streptococci pose a risk. Life threatening infections with the latter
can result from quite trivial contact and injuries. Therefore, great care
should be taken during post mortem with appropriate personal protective
clothing and careful technique

Gastrointestinal Pathogens

Faecal leakage from bodies is very common. All those handling cadavers
should:
• Wear single-use gloves and impervious single-use aprons.
• Take care not to contaminate their instruments or their working
environment.
• Wash their hands carefully after procedures and before eating, drinking,
or smoking.
• The bodies of those who have died of diseases such as cholera or
typhoid should not be buried in places where they could contaminate
water sources.

Transmissible Spongiform Encephalopathies (TSEs)

These are rare conditions typically presenting as Creutzfeldt-Jakob and

variant Creutzfeldt-Jakob disease. The causative agents of these diseases
are highly resistant to most disinfectants and to heat. They are not
inactivated reliably by chemical disinfection or conventional heat
sterilisation. Only fully trained staff should undertake post mortem
examinations in patients thought to be at risk of, or who are known or
suspected as having, TSEs. If examination of the brain only is required, the
skull should only be opened inside a large plastic bag fitted over the head

5
and neck of the cadaver. In addition, full single-use personal protective
equipment (PPE) (including coverall, apron, double gloves, full face visor, or
surgical mask and eye protection) should be used. If a full post mortem is
required, including the removal of viscera and spinal cord, the body should
be examined in a high-risk autopsy suite.

Hepatitis

• Hepatitis A is transmitted by the faecal-oral route and presents the same

hazard as other gastrointestinal pathogens. A highly effective vaccine is
available.
• Hepatitis B is extremely infectious and the incidence of this infection
continues to increase in many countries. A highly effective vaccine is
available and staff working in hospital mortuaries and embalmers
should routinely receive immunisation against this infection. The bodies
of those who have died of, or were known to be infected with, this virus
should be handled only by those wearing full protective clothing.
• Hepatitis C is also highly infectious, although probably less so than
hepatitis B. It is transmitted by the same routes as hepatitis B, there is
no vaccine, and similar precautions to those for hepatitis B should be
taken.

HIV

The routes of transmission of hepatitis B and of HIV are similar and the
precautions required to prevent the transmission of the former should be
adequate to prevent transmission of the latter. HIV is less infectious than
hepatitis B and the risk to those handling infected cadavers is therefore
proportionately less. HIV can survive for many days post-mortem in tissues
preserved under laboratory conditions. Care should be taken when handling
unfixed, HIV-infected material from cadavers, or when undertaking post-

6
mortem examinations on those infected with HIV. Embalming the bodies of
those known or suspected of being infected is not recommended.
Those infected with HIV are often infected with other organisms (such as
mycobacteria), which may be more infectious (albeit less dangerous) than
the HIV infection itself.

Viral Haemorrhagic Fevers (VHFs)

Viruses such as Ebola and Marburg are highly infectious and are readily
transmitted by contact with infected blood, secretions, and organs. Most of
the known outbreaks of these zoonotic viruses have started with
individuals who acquired their infections from wildlife but have spread via
healthcare facilities (when staff have unknowingly become infected from
the index case(s) and have subsequently spread the infection to other
communities where they live and work). Great care should be exercised
when dealing with those who have died of such infections and staff should
be trained in the handling of cadavers in these situations. WHO advises
that those who are handling the dead body of a suspected or confirmed
case of VHF should wear the full set of PPE that is recommended for those
treating live cases (listed below), together with heavy-duty rubber gloves.
• Double gloves (non-sterile examination gloves).
• A single use gown or coverall resistant to penetration by blood or body
fluids.
• A waterproof apron worn over the gown or coverall. (If single use aprons
are not available, heavy duty, reusable, waterproof aprons can be used if
appropriate cleaning and disinfection can be performed).
• A filtering facemask giving protection equivalent to US NIOSH standard
N95 or European standard FFP2.
• Eye protection (either goggles or face shield) in order to have the
mucous membranes of the eyes, mouth, and nose completely covered
by PPE and prevent virus exposure.
• Waterproof boots (e.g. rubber/ gum boots).

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• Note: While those who handle the dead are unlikely to be exposed to
aerosols and therefore do not need to be protected against aerosol
exposure, the majority of the teams responding to the Ebola crisis in
West Africa in 2014-15 found that it was best to use a single type of
facial protection for all those involved with the handling of Ebola cases
(despite the cost and supply implications), so as to reduce the risk of
error in such a high stress situation and also to maintain morale
amongst staff.
• CDC has also produced similar advisory material regarding the
protection of those dealing with VHFs.
• Post mortem examinations should not be carried out. Bodies should be
bagged as soon as possible and should be buried with appropriate
precautions (see below) or cremated.

Reduction of risk

• Post-mortem rooms.
1. Post-mortem rooms should be structured such that the risks to those
working in them are minimised. Provision of adequate ventilation,
lighting, running water, and good drainage is essential.
2. Workers must use single-use gloves for each procedure and, after
removal, wash their hands immediately.
3. The environment should be cleaned with a broad-spectrum
disinfectant daily.
4. Instruments should either be washed in a washer-disinfector and
autoclaved, or they should be cleaned and then boiled (in areas with
limited resources), or immersed in a broad-range, non-corrosive
disinfectant after initial cleaning. Any manual cleaning needs to be
done very carefully; this stage is where puncture of the operator’s
skin with sharp contaminated instruments is likely.
5. Hypochlorites (e.g. chlorine bleaches) should not be use because:

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 o Hypochlorite is corrosive and may damage surfaces or
instruments.
o Formaldehyde is likely to be present in postmortem rooms.
o And the reaction between hypochlorite and formaldehyde can
produce a potent carcinogen (bis-chloromethyl ether).
6. Some hospital post-mortem departments bag all bodies for transfer
to funeral directors. This can be counter-productive in terms of safety
as bagging a body may be the main means by which the hospital can
communicate to the funeral director that the body may present
special risks. In countries where confidentiality precludes reference
to specific infections, the type of risk involved can be identified by
attaching labels advising generic precaution types (e.g. enteric,
bloodborne) to the bag.
• Preparation of the dead for funerals.
1. Often only a simple "hygienic preparation" may be carried out,
frequently by relatives or religious officials. This usually involves
washing the body, dressing the cadaver, tidying the hair and possibly
trimming the nails and shaving. In some societies, this is an
important part of the ritual of dealing with the dead (for example
traditional burials in West African countries) and may involve very
close contact with the cadaver (embracing, kissing, etc.). Such rapid
procedures are frequently followed in many countries, particularly the
hotter ones, where burial or other disposal of the cadaver follows
death within 24 hours (either for practical or religious reasons). Under
these circumstances many pathogens may still be viable but,
provided there is considered to be only a low level of risk, then the
use of gloves and simple protective clothing and/or good personal
hygiene by anyone handling the bodies is an acceptable and effective
safety measure.
2. In some instances, for example where the person has died of a highly
infectious disease such as Ebola or hepatitis B, even hygienic
preparation is not safe (see the list of such infections in Table 41.2).

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 Under these circumstances, the risks to those handling the cadaver
may be very high. It has been estimated that during the recent
outbreak of Ebola in West Africa (2014-16) as many as 65% of those
who were involved in unsafe burial practices became infected and
that unsafe burial played an important role in the size and extent of
the epidemic.
3. Embalming may be undertaken as a means of temporary
preservation by reducing microbial activity and slowing
decomposition and is usually a straightforward process, but the
embalming of cadavers which have been in accidents or which have
been the subject of post-mortem examination is more difficult. They
may be badly damaged and present particular hazards because of
damaged bones, bone splinters, and (occasionally) due to sharp
items, such as intravenous cannulae, left in the body. Cosmetic work
on cadavers may also present hazards if the body has been
damaged. There can sometimes be considerable contamination of
the body with blood, faeces, and other body fluids if it is bagged,
presenting an extra risk to embalmers and others involved in
preparation of the body. This is another reason to avoid universal
bagging of bodies by hospitals. Embalming practices such as the
open drainage of the vascular system lead to excessive
environmental contamination and should be avoided.
4. All instruments used for embalming or for preparing bodies for the
funeral should be carefully cleaned in detergent and either sterilised
in an autoclave, boiled, or soaked in a disinfectant. Disinfectants
should be used to clean up any spills of blood or body fluid, single-
use gloves being used to protect the hands from contact with the
spill. Hands should always be washed after finishing a session.
5. As with post-mortem rooms, hypochlorites (e.g. chlorine bleaches)
should not be used (see above).
• Emergency service personnel.

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 1. The major hazard facing emergency service personnel is spilt blood
and any risk can be greatly reduced by preventing contact with blood
(use of gloves, face and eye protection, and protective clothing where
necessary).
2. Bodies that have been decaying for some time, including those that
have been in water for extended periods of time, present little risk.
The organisms likely to be present are their own body flora and water
or other environmental organisms. The use of proper protective
clothing and good personal hygiene will protect personnel handling
such material.
3. Bodies should always be transported to mortuary facilities in
waterproof body bags or cleanable, fluid retentive (e.g. fibreglass),
temporary coffins.
• Disposal of the dead.
1. Each society has its own methods of disposal of the deceased.
These must be respected as far as possible although in a few
instances (such as deaths due to highly infectious agents such as
Ebola) cremation or deep burial with the cadaver in a leak-proof
plastic body bag may be the only safe procedures.
2. Immediately following disasters where there has been substantial
loss of life, there seems to be a tradition to bury or cremate the dead
as quickly as possible “to prevent the spread of disease.” In reality
however, the dead bodies of disaster victims pose a minimal
infectious risk to the survivors. The spectrum of disease amongst the
deceased in a rapid onset disaster will be the same as that amongst
the survivors. Of those deceased that had an infectious disease at
the time of their death, the risk that they will disseminate it will be
lower than it was during their life and those that did not have an
infectious disease offer a negligible risk. The imperative of
immediate disposal of the dead diverts resources from searching for
and caring for the survivors at a critical time in any rescue operation.
It also hampers or prevents the identification of the dead, removing

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 part of the grieving process from their relatives, as well as prolonging
their uncertainty as to the possible survival of the victims. The legal
consequences of lack of identification (e.g. uncertainty of spouses
about death of partners, inheritance, or welfare benefit problems) can
cause long-term hardship for the deceased relatives.
3. If bodies cannot immediately be identified and sufficient temporary
mortuary space with refrigeration is not available, they should be
buried in marked graves with at least one metre (3 feet) of earth over
the cadavers (to prevent access by scavengers and pests) to allow
subsequent exhumation if permitted. Careful and detailed records of
such interments must be kept. Once identified, they should be dealt
with following the normal religious and social practices of the
affected areas as far as possible. Burial sites must be chosen so as
to avoid the risks that water sources may be contaminated.
4. Those handling the bodies should take basic infection control
precautions: impervious gloves, single-use or disinfected after use),
impervious apron or coverall, impervious footwear, and face
protection if splashing is likely. Respiratory-protective masks are not
necessary. The use of chloride of lime to prevent the spread of
infection in these circumstances is to be avoided. It has little effect
and is dangerous to those applying it. This applies equally to
emergency and non-emergency situations, such as exhumations of
graves and crypts.

SUGGESTED PRACTICE IN UNDER-RESOURCED SETTINGS

The practices listed above are equally applicable to under-resourced
settings.

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SUMMARY
Infectious risks from human cadavers are of a lower level than those from
living individuals who have active disease or who are carriers of infectious
agents. Preventing infection from those who come into contact with those
who have died of infectious disease is primarily concerned with preventing
direct contact with blood and other body fluids, particularly to mucous
membranes or broken skin. Such contact should be prevented by using
safe procedures or, where this is not possible, the use of appropriate
personal protective equipment. This should be done without compromising
the dignity of the deceased and, wherever possible, not interfering
excessively with the grieving processes of their relatives. In large scale
natural disasters (and also in complex emergencies), the pattern of disease
is generally the same in the deceased as in the survivors and the deceased
present a minimal risk. The mass disposal of the remains of those who
have died in such disasters should be done in such a way as to allow easy
exhumation for identification purposes in the future.

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 Table 41.1 Use of Protective Clothing
Hands
Examination gloves (latex or nitrile): For handling hazardous material.
Wear whenever handling bodies. Should be worn once only and then
discarded. Always wash hands after use. Latex gloves provide short-term
(10-minute) protection against formaldehyde; nitrile gloves give longer-
term protection.
Respiratory Protection
Filter masks: Filter mask to EN 149 FFP2 (or equivalent, e.g. N95) for
specific hazards (e.g. lead dust, fungal spores, and other aerosols)
Specifically-manufactured surgical masks: These may provide protection
against splashes, particularly if water-repellent, but cannot be as
effective as filter masks as their fit to the wearer’s face allows particles
to bypass any filtration the mask fabric may offer.
Cloth surgical masks: These provide little protection and may give a false
sense of security, but are better than nothing.
Splash Protection
Face: Visor. Protection against hazardous splashes to eyes, nose and
mouth (also mechanical protection).
Respiratory protective masks and cloth or paper surgical masks normally
provide splash protection to mouth and nose only.
Some surgical masks incorporate a transparent eye-protecting visor.
Body: Apron. Where splashing to body may occur (hygienic preparation,
embalming, collection of traumatised bodies, post-mortem
examinations). Best worn under gowns or coats if splashing is likely to
be profuse.
Feet: Rubber boots. In wet situations (mortuaries, embalming rooms,
collecting severe multiple trauma cases).
Whole Body Protection
Gowns/coats: To protect clothing against splashing.

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 Coverall with hood: To protect clothes and hair from impregnation with
dusts, spores, etc.
Other protective clothing (safety helmets, boots, safety glasses,
work gloves) should be worn as required to protect against
mechanical injury.

Table 41.2 Infections Where Bagging is Essential and Viewing,

Embalming Cosmetic Enhancement, and Hygienic Preparation
Should Not Be Done
INFECTION
Anthrax
Plague
Rabies
Smallpox
Viral haemorrhagic fevers
Yellow fever
Transmissible spongiform encephalopathies (e.g. Creutzfeldt-Jakob
Disease) Streptococcal disease (group A)
Viral hepatitis (B, C, non-A non-B)

Bagging = placing the body in a leak-proof plastic body bag.

Viewing = allowing the bereaved to see, touch, and spend time with the
body prior to disposal.
Embalming = injecting chemical preservatives into the body to slow the
process of decay.
Cosmetic enhancement of the appearance of the body may be
undertaken to improve the appearance for viewing.
Hygienic preparation = cleaning and tidying the body so it presents a
suitable appearance for viewing (an alternative to embalming).

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