CREMATION OPTIONS REFOCUSES ON CJD
Recent events in Idaho and an increased number of inquires by funeral service professionals on NFDA’s OSHA support line justify a refocus on Creutzfeldt-Jakob disease (CJD) and the proper precautions an embalmer should take when facing a confirmed CJD case in order to minimize potential transmission of the disease and remain in compliance with OSHA laws, standards and regulations. CJD infectivity is found in high concentration in the brain, spinal cord and the eye itself. It also is found to a much lesser degree, in cerebral spinal fluid, and possibly in blood. The disease apparently does not cross barriers of intact skin or adjacent mucus membranes, but transmission is possible through a penetrating injury. CJD is always fatal and based on current scientific data is still considered untreatable. The primary hazard in embalming and preparation is that CJD has a high resistance to customary means of decontamination, such as boiling, irradiation and the use of chemicals, such as alcohol, phenols and formaldehyde. In their place the use of steam under pressure for instruments (autoclaving) incineration and chemical exposure to sodium hydroxide or bleach for an extended period has been recommended. OSHA still does not provide a separate funeral specific standard for hazardous exposure to CJD and instead relies upon its existing Bloodborne Pathogen disinfection recommendations for CJD are not directly referenced in this standard, however leaving the question open as to what steps a funeral director should follow in the removal, handling and embalming process in order to remain in compliance with the standard and moreover to safely handle a confirmed CJD case, given its undisputed resistance to disinfection.
CJD & OSHA
The funeral and cremation service professionals must be aware that OSHA considers CJD a known hazard in the health-care profession and in funeral service. Therefore this fact clearly requires employers to take all additional steps necessary-beyond those required by a specific OSHA standard -to protect employees against exposure to CJD. In general the OSHA Bloodborne Pathogen Standard requires universal precautions, meaning that all human blood and certain body fluids must be treated as if they are known to be infectious for HIV, hepatitis B and other Bloodborne pathogens. Per an OSHA inspection Directive this includes CJD. In addition employers must implement engineering controls that isolate or remove the Bloodborne pathogen hazard from the workplace and initiate work-practice controls that reduce the likelihood of exposure to the Bloodborne pathogen by altering the manner in which employees perform a task. When an occupational exposure to a Bloodborne pathogen exists, employers must provide-at no cost to the employee-appropriate personal protective equipment such as gloves, gowns, laboratory coats, face shields or masks, and eye protection. Each of these items will only be considered appropriate if the device does not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucus membranes under normal conditions of use and for the duration of time that the personal protective equipment will be used. Requirements also exist for disposable equipment, housekeeping, an exposure control plan, training and the labeling of biohazards.
Protection against CJD requires additional protection and procedures specific and unique to this disease. Because of its unusually high risk, mortality rate and resistance to normal disinfection procedures, these CJD specific procedures, workplace controls and engineering controls must appear in the employer’s Bloodborne Pathogen Exposure Control Plan, and specific training must be given and documented in their appropriate use. If using sodium hydroxide as a disinfectant as some have recommended for a CJD case, funeral professionals must be aware that sodium hydroxide is a regulated air contaminant under Table Z-1 of the OSHA Air Contaminant Standard, 1910.1000. According to the table an employee’s exposure to sodium hydroxide is limited to two milligrams per cubic meter, during an eight hour time-weighted average. If using sodium hydroxide as a CJD disinfectant funeral service employers must ensure that an employee’s exposure to this substance does not exceed this time-weighted average during any eight hour shift of a 40 hour work week. To achieve compliance with this requirement if using sodium hydroxide, employers must conduct air sampling to determine if an overexposure hazard exists and if so implement administrative or engineering controls to reduce exposure to within the stated limit. When such controls prove infeasible, employers must provide personal protective equipment, such as respirators. In addition if a respirator is required because of the potential overexposure to a disinfecting chemical, such as sodium hydroxide, the respirator must be provided and used in a manner consistent with the OSHA Respiratory Protection Standard, 1910.134.
This not only requires providing an appropriate respirator as protection against a specific chemical exposure, but also requires a Respiratory Protection Program, fit-testing of the respirator, a medical determination regarding the employee’s ability to use a respirator, an inspection and maintenance program for the respirators, and employee training regarding their safe use and maintenance, along with other stated requirements. Many writers and organizations such as the World Health Organization do not encourage embalming autopsied remains of remains with traumatic injuries. Others have claimed however that embalming can be performed using disposable masks, gowns and gloves; placing the body on an impermeable sheet to contain leakage; arranging drain sites to limit surface contamination; collecting body fluids in a stainless steel container; closing incisions with glue and wiping down the body with bleach; an decontamination the container of body fluids using sodium hydroxide while avoiding spillage and the heat the fluid will generate. There are also specific requirements for the amount of time that mortuary waste must be kept in the container, requirements for the disposal of sheets and disposable items via incineration and flooding contaminated surfaces with sodium hydroxide or bleach. The latter again might create a chemical hazard and require CJD specific disinfection instructions. If following these procedures pay rigorous attention to the containment of potentially infectious materials including the prevention of penetration injuries by possibly contaminated instruments, and the avoidance of splashing of blood or spinal fluid onto the skin, lips or eyes. Significantly such cuts must be treated like a venomous bite, which would include bleeding the cut, chemical disinfection and washing with large amounts of water.
CJD & WORKERS COMP
A second issue concerning CJD concerns its potential workers compensation impact should exposure occur while embalming a CJD case. Workers compensation statues are creatures of state law, with each state enacting and enforcing its own version of workers compensation. In general however for an employee to recover for an injury or illness, the employee would have to show that the condition occurred, arose out of or had a relationship to employment. Given the relatively long time that it takes for CJD to develop after an initial period (which could be up to 25 years), it would be difficult to establish a casual relationship when the disease surfaces. In practical terms this means that a workers’ compensation insurance carrier might deny coverage and the exposed employee would face the dilemma of proving a work relationship and jobsite work exposure for CJD even I the diagnosis of CJD is not in dispute. This is especially problematic since a number of CJD cases apparently have been and continue to be, inadequately documented or mischaracterized, even though CJD is considered an emerging infectious disease. IF preparation is to be performed on a confirmed CJD case a funeral home owner should consider providing increased health and life insurance coverage for the embalming staff and verify that any existing insurance policies do not contain exclusionary language that might limit or prevent a claim for CJD being brought. In some cases this might require additional coverage or adding a rider to an existing policy.
PARTING THOUGHT
It is clear that when facing a confirmed CJD case in which the remains are not intact, due to either autopsy or physical trauma, direct cremation or direct burial is still the safest procedure. If the remains before cremation or direct burial are placed in a sealed casket a memorial service can also be held without hazard. If embalming a CJD case in which the remains are intact and were not autopsied, the presence of CJD still requires scrupulous compliance with applicable safety and health regulations, even though the hazard to the embalmer is greatly reduced. Unless a funeral service practitioner is trained to handle the specific requirements needed for CJD case and is fully committed to scrupulously complying with these requirements the preparation of a CJD case should not be attempted.
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