An epidemic has the potential to greatly alter the common practices of all sectors of the funeral industry in terms of the basic bereavement services, preparation of the body, and other considerations—most notably the safety of the funeral industry professionals and the family and friends of the deceased. In the case of an epidemic there are several guidelines to follow to ensure that further transmission of the disease and epidemic is not possible and although there are resources for funeral industry members to consult in the case of such an event, some of the precautions and processes involved with dealing with epidemics involve a great deal of common sense knowledge and practical application of training and create an extreme palliative care crisis.
While it is always important to observe basic sanitation protocol in the funeral industry, this becomes an issue of paramount concern in an epidemic situation. Furthermore, aside from attempting to minimize the risks associated with epidemics (which are localized outbreaks of a disease—as opposed to the global-scale pandemics) in regards to transmission, it is also important to recognize the fact that the families of epidemic victims are deserving of respect and a service adjusted to their faith if this is at all safely possible. It is up to the funeral industry to both provide a safe means of interment as well as deal professionally with the grief that an onslaught of epidemic-related deaths in a pinpointed area will cause.
Although cholera epidemics have been scarce in the United States and other developed countries, third world nations still deal with outbreaks on a regular basis. While the exact reason for particular outbreaks varies on a case-by-case basis, it is known that “cholera is transmitted through ingestion of substances contaminated with the bacterium. The contamination usually occurs when untreated sewage is released into waterways, affecting the water supply, any foods washed in the water and shellfish living in the affected waterway—it is rarely spread directly from person to person. The resulting diarrhea allows the bacterium to spread to other people under unsanitary conditions.” In underdeveloped countries, this lack of adequate sanitation and oftentimes knowledge about the dangers of cholera has led to many epidemics. In such countries, it is important for funeral industry workers to have keen knowledge of the way the disease is passed and realize that it is not only through contaminated water, but also by unprotected contact with the body.
“Because a corpse will commonly leak feces, persons handling dead bodies are more likely to be exposed gastrointestinal organisms (such as cholera) than to blood-borne viruses. Workers may be exposed through direct contact with the victim’s body and soiled clothes, and transmission can occur via the fecal-oral route.” While this should provoke caution in handling the body itself, it is also important to note that equipment used by the funeral industry such as storage, vehicles, and stretchers may also be affected, thus disinfecting the area thoroughly is an absolute necessity. Ultimately, while the funeral industry is expected to follow general guidelines regarding sanitation, the greatest and most important change that will arise as the result of an epidemic of cholera (or other bacterial/gastrointestinal-related epidemic) is a heightened process for disinfection—both of the body itself during preparation and of the surrounding area.
Cholera carries a very low mortality rate (<1%) when treated adequately, but a high mortality (>50%) if untreated. Treatment is simple (rehydration with oral or parenteral fluids) and inexpensive, but not available in many parts of the developing world. Therefore deaths from cholera cluster in the poorest countries. In some countries in West Africa, such as Guinea-Bissau, not only is adequate treatment unavailable, but also cultural rituals that surround the death of cholera victims perpetuate the disease. There have been notorious cases where cholera victims have been set out at a funeral service which involved a great deal of contact with both the dead and the people (since family members as well as professionals help prepare the dead) that washed the body went on to hold a funeral feast, thus transmitting the bacterium from the body to the community, causing an epidemic.
“The 1994 cholera epidemic in Guinea-Bissau resulted in 15878 reported cases and 306 deaths. Early in the epidemic, although the health ministry mandated that the bodies of persons dying of cholera be disinfected, outbreaks occurred in several villages following funerals in the region of Biombo.” It was found later that the directions for the disinfection were not adhered to, thus one cholera death’s funeral feast led to progressively more funerals. In order for the funeral providers in Africa during this epidemic to provide safe services, a change in the cultural practices was necessary and thankfully, cases similar to this have been lessened—in part also simply because only a few rural tribes hold such funeral feasts.
The above example, while in an entirely different context and scenario than one in which a Western, particularly an American funeral industry worker would be placed, illustrates the need for diligent attention to sanitation—both of the body and the area—in the case of an epidemic of such a disease. It demonstrates how easily the bacterium can be passed and that there are precautions to take in order to prevent the spread to oneself as well as those grieving for the cholera victim. “Funeral directors have specific duties to ensure that visitors to their premises are protected, as far as is reasonably practicable, from harm. This is particularly important where there may be an infectious agent present. Many bereaved people find it had to accept that there is a risk of infection, particularly if they have nursed or visited the, soon before their death, thus denying them the opportunity to view the deceased can also be a source of great distress. However, this does not remove the legal obligation of the funeral directors under the health and safety laws” Along with basic heightened sanitary measures then, the effect on the funeral industry would be two-fold; the sanitary concerns versus the wishes and needs of the bereaved family members. There cannot be a choice between these two issues in the event of a dangerous and widespread epidemic and it is important to realize the dangers of transmission and inform the family members of possible risks. Even though it is vital for the body of a cholera epidemic victim to be completely disinfected, this is a tough situation since there can be no absolute assurance that there hasn’t been some contact with infected material. While there are no standards in place preventing the family members to touch the dead or for funeral directors to demand a closed or hermetically sealed coffin, the discretion used should always err on the side of caution.
In the case of an epidemic of cholera or other associated gastrointestinal disease with the same characteristics of transmission, the most vital element in the preparation of the body is complete disinfection. The process of embalming and the fluids used are meant to retard the decay of the body, to disinfect, and to provide a better appearance to the body for viewers. While this process may be successful in disinfecting, it is important to consider more personal issues during the actual embalming procedure. According to a 2005 survey, “: 92 (17%) of morticians reported splashes to mouth or eyes in a typical month and 15 reported more than 3 such incidents. In this survey, 15 (3%) of morticians also reported at least one percutaneous (needle stick and cuts) exposure to blood of a decedent with ante-mortem diagnosis of AIDS; 10 (2%) reported needle stick exposure and 5 (1%) exposure from cuts. Four morticians also reported skin contact with blood.” While observing basic personal safety measures is vital in every non-epidemic case, these types of blunders can have a much larger impact if allowed to happen, thus spread the disease to others. In the case of embalming an epidemic victim, there is no question that the efforts to ensure extra care in the embalming followed by an extensive sanitation regimen of the area is the most important step in preventing transmission.
n the case of cholera epidemic victims, observing the extra caution mentioned above should also be extended to any moving of the body. It is necessary to avoid any contact with fecal matter that may be expelled and extra care should be taken when moving the body. Washing with low water pressure and avoiding any sudden movements that may expel the bacterium is important as well as are the more general guidelines of gowns, gloves, protective eye wear, appropriate disposal of waste, and thorough disinfection. If a funeral industry worker were dealing with such an epidemic in Africa or another underdeveloped region, these same guidelines would certainly apply. Also, since the number of deaths is likely to be far higher in such regions, there are other standards set forth by the World Health Organization for funeral industry workers in third world areas devastated by the outbreak of epidemics. One of the key factors they cite deals not with the preparatory aspect, but the disposal of the corpses. Contrary to common belief, there is no evidence that corpses pose a risk of disease “epidemics” after natural disasters. Most agents do not survive long in the human body after death (with the exception of HIV – which can be up to 6 days) and the source of acute infections is more likely to be the survivors. Human remains only pose health risks in a few special cases requiring specific precautions, such as deaths from cholera or hemorrhagic fevers.” This study also goes on discuss the aforementioned processes of disinfection but does make it clear that in an epidemic situation there may not always be time to take precautions for each individual body. In such a case, a complete disinfection of each corpse is vital before interment into the ground, but in some ways this does not seem like the most effective approach in an epidemic situation with mass fatalities. In a report, the WHO suggests, ““Victims should never be buried in common graves. Mass cremation of bodies should never take place when this goes against the cultural and religious norms of the population.” Although there has not, to date, been a cholera epidemic that has required mass cremation, it is a last resort in the case of many deaths—especially if the resources to properly disinfect all of the affected bodies are not present. If there are, however, adequate supplies to properly and safely go through with the embalming process, there are further specifications for burial offered by the World Health Organization. They indicate “graveyards should be at least 30m from groundwater sources used for drinking water and that the bottom of any grave must be at least 1.5m above the water table with a 0.7m unsaturated zone. Surface water from graveyards must not enter inhabited areas.” Although the case has not yet arisen in which mass graves or funeral pyres have had to be constructed (at least by Western funeral industry members noted in relevant literature) the issue of body disposal, as well the disinfection process is also important. While most report cite the fact that mass cremation is not the preferred method of disposal, there could be a case where this would become necessary Until that time, Disposal of bodies should respect local custom and practice where possible. When there are large numbers of victims, burial is likely to be the most appropriate method of disposal. There is little evidence of contamination of groundwater from burial” although the World Health Organization stresses it that proper disinfection is key to preventing the spread through groundwater.
A policy of disinfection of corpses in the few places in the world where the cultural practice is for the patient’s caregiver or handler to prepare the funeral feast may decrease the spread of cholera, although there is little supporting evidence for this uncontrolled observation. Cholera can, however, be prevented by adequate hand-washing before preparation of food, and by decontamination of drinking water and other water that is used in food preparation. Another option is to discourage the holding of funeral feasts for cholera victims. All three measures involve behavioral changes, which are always difficult to effect. The case in Africa cited above is illustrative of the general lack of knowledge about disease transmission and the handling of corpses. While it cannot be argued that Western modes of mortuary science and law indicate that many protocol be fulfilled in terms of sanitation, handling, and interment, perhaps there should be some extra efforts directed at underdeveloped nations in terms of proper and safe disposal of corpses. For those grieving, it may seem appropriate to touch the dead or kiss and handle them but when combined with the ingestion of food during an act, this is quite dangerous. There have been some culturally-sensitive proposals introduced, such as encouraging the tribe to wait a few days after the funeral before holding the feast and making sure that within that time the body is interred safely.
Cholera has not been entirely wiped out—even in developed nations. There are instances of contaminated water transmitting the bacterium even in stereotypically “developed” places such as New York, Detroit, and Cleveland. Although these cases were not always fatal, the fact remains that Western countries must be vigilant to the risks. It seems as though the funeral industry could fall into the trap of thinking that such diseases no longer pose a threat, but doing so would be a great fallacy. New “super-germs” and strains of previously harmless or mild bacteria are being found, thus taking cues from such third world areas is important. Warning those who conduct funerals in developing countries about the possible dangers associated with handling cholera victims should be the first step in eradicating the instances of cholera outbreaks and hopefully, with further worldwide education on the subject, cholera will be just as rare there as it is in the United States
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