First of all, a basic review of some embalming fundamentals. Embalming is defined by the following three terms:

Disinfection
Preservation
Restoration

A person who dies from CJD will not present any particular challenges to preservation. The selection of embalming fluid, fluid strength, and fluid volume will be the same as a similar body deceased from any other cause.

Similarly, the appearance of the body will be no different than that of a similar body deceased from any other cause. No special restorative techniques will be necessary.

However, CJD is resistant to formaldehyde and every other embalming fluid component or disinfecting chemical including gluteraldehyde, phenol, and alcohol.

Nothing you can do with the body will render it disinfected.

Therefore, by definition, you can not technically embalm a person who is deceased from CJD.³⁷

You can produce tissue firmness and preservation. You can produce a pleasant cosmetic effect. But you have not really embalmed the body.

When you have completed the arterial injection, the disease organism is just as much alive as it was when you began.

While there are no industry-specific standards of protection for mortuary staff when discussing CJD, we can emulate what is done in the medical field.

Most pathology departments have additional guidelines for handling patients deceased from CJD.

Typically this includes wearing two or three pairs of disposable gloves, (rubber or latex, never vinyl) protective eye covering and face shield, mask, cap, jumpsuit, waterproof apron, and shoe coverings. (Hospital guidelines go beyond what is normally considered "standard" universal precautions when dealing with CJD.)

Avoid causing aerosol distribution of contaminants. Avoid contact with all tissues and body fluids.

All solid waste should be placed in a leak-proof container and disposed of by incineration.

Instruments should be disinfected by autoclave or incinerated. They can also be containerized and disposed of as medical waste.

All surfaces should be wiped with sodium hypochlorite. Despite its shortcomings, the use of ordinary household bleach is recommended for general disinfective use in the embalming room and especially when dealing with CJD. Surfaces that may be contaminated should be wiped with a .5% solution (1:10 dilution) of bleach.^{38 39}

Since the organism has also been isolated in several internal organs, aspiration of the body should not be attempted.⁴⁰ Minute pieces of the internal organs can be aspirated into the trocar, exposing the embalmer to the organism, and the trocar will remain contaminated after the process is completed.

Like other diseases, we are going to be exposed to CJD unknowingly. But when we know or suspect the presence of CJD, we can take steps to protect ourselves. We can not totally eliminate the risk of exposure to any disease, but when we know it is present, special care is warranted.

Finally, you would be well advised to consult with local public health authorities prior to attempting preparation to see if special handling of the case is required. Most states and counties have regulations concerning the handling of infectious disease cases. Whether or not it is specifically named in the regulations, CJD is an infectious disease. There may be restrictions on shipping, public viewing or other exposure to the general public.

The CJD organism is concentrated in the brain and spinal column. While we might assume that exposure to the CJD organism is rather limited when handling the "normal" case, the embalmer is fully exposed to the organism when an autopsy has been performed, when death follows neurosurgery, or when death is due to head trauma.

The embalmer is well advised to request that the body be placed in a body pouch following autopsy to minimize contamination of the cot and removal vehicle or exposure of the removal personnel.

If restoration of the remains is attempted, all instruments, the embalming table, embalming room, and embalming room personnel are exposed to the organism and there are no procedures available that will guarantee rendering the organism harmless. The organism can remain viable for over a year.

Limit the number of people who are exposed to the body by limiting admission to the preparation room during the preparation process. Exposure to others after the body has been repaired should also be limited. This would include other embalmers, hairdressers, cosmetologists, etc.

There have been no specific tests done to determine if the prion is destroyed during the cremation process. This has led some to speculate that the prion is some type of super-bug that can not be destroyed. Incineration has been shown to destroy the prion at 1000 degrees. Therefore it is reasonable to assume that cremation, which is also essentially incineration, also destroys the prion. Also, since the prion is normally destroyed during autoclaving which is steam under pressure at 130 + degrees, we can safely assume that the 1660 + degree crematory will also destroy it.

Likewise, there have been no specific tests as to what happens to the prion when it is buried. Since we know that the prion can live for a year under normal conditions, there is no reason to believe that it can survive any longer than that underground. Assuming that the body remains intact inside the casket or casket and vault for at least a year, the interred body should pose no threat to the environment or underground water sources.

Knowing what we know about CJD (and probably more importantly, what we don't know) the question must be asked.

Should an embalmer attempt to embalm a body with CJD?

Some funeral directors that have been called on to serve a family where CJD is the cause of death have had this question answered for them. The family physician has already told the family that they can not expect to have the body embalmed, have a public viewing, or a funeral. Some families have been told that the body should be cremated immediately upon death.

There is no reason for a family to feel obligated to choose cremation. By use of a body pouch and/or a sealing type casket, there is no reason why an unprepared body with CJD can not have a public funeral and an earth burial.

While we may not agree with the conclusion reached by the physician, we should at least note the seriousness he attaches to this disease.

Whether or not an embalmer agrees to prepare the body is a personal decision that should be weighed carefully.

It is quite different from the questions we faced years ago when AIDS was first identified. Even though we did not know much about AIDS initially, we had an effective embalming technique and the chemicals available to render it harmless if we were careful in our procedures.

While the Americans With Disabilities Act (The ADA) has made AIDS a disability and requires embalmers to embalm AIDS cases or risk civil liability, the refusal to attempt to do what is impossible is an entirely different matter.

Since neither the Department of Justice nor the courts have ruled on the issue of handling CJD. A funeral home refusing to attempt preparation may indeed have to defend their decision if an ADA enforcement action is brought against it.

The case will hinge on whether this risk of CJD can be eliminated by "reasonable modifications" to the embalming process.⁴¹

Since no embalming fluid exists that will render the prion harmless, it would be argued that there is no "reasonable modification" to be made.

The threat of defending oneself from an ADA complaint must be weighed against the personal health risks involved.

The other difference that we can note between the history of AIDS and the history of CJD is that within months of its discovery, we knew a lot about AIDS; what it was, how it was transmitted, etc. CJD was identified over 70 years ago and still we know very little about it.

With CJD, the question of preparation can only be answered after carefully considering the facts and weighing the consequences.

• We are being confronted with a 100% fatal disease.
• There is no cure; there is no treatment.
• There is no vaccine.
• The mode of transmission of this disease in humans is largely unknown.⁴²
• There is no effective embalming treatment.
• There is no effective disinfecting technique for instruments, equipment, or the preparation room itself.
• The organism can survive and remain viable for over a year, possibly infecting others during that time.
• You may become infected with this disease and not know it for decades.

It would appear that CJD is not a vicious, rampant, killer organism intent on wiping the human race from the face of the planet. The numbers indicate something far less than a worldwide epidemic, to say the least. There is no need for panic or hysteria. We are not facing Black plague or Ebola.

However, it is a fatal illness and we can not take that lightly. And it is not a disease we can do much with, either by way of protective measures or embalming technique.

Universal precautions coupled with cautious, deliberate work practices and a dose of plain common sense will do much to reduce the exposure risk.

But the risk can not be eliminated and the full extent of that risk is unknown.

Is it worth it?

How much risk are you willing to take?

If you determine that the risk of infection is minimal in the "normal" case and attempt preparation, do you still refuse to attempt preparation of the autopsied case where the highly infectious brain, spinal column, and cerebro-spinal fluid are exposed?

Should you refuse to attempt preparation when there is no concrete evidence that you can be infected with CJD in the preparation process? What happens if it is proven that there is no risk of CJD infection from a dead human body? What happens if it is proven that infection is possible?

If you refuse to prepare the body, will the family choose another funeral home? What effect could this refusal have on your reputation of service within the community? What liability might a funeral home face if they refuse to attempt preparation?

What liability might your funeral home face if it is shown that an employee contracted CJD from a body that they prepared in your funeral home?

What moral obligation do you have to protect your employees versus your moral obligation to serve the public?

Although not specifically addressed by OSHA, the "General Duty Clause" of the Bloodborne Pathogen Standard would require the employer to protect employees from a known hazard. Since CJD is certainly a known hazard, employers would be required to protect their employees from this hazard.

It would appear that CJD would require steps beyond that of "universal precautions" and indeed the question is-- can the employer adequately protect their employees from CJD if preparation is attempted?

Some surgeons have refused to operate on a person known to be infected with CJD. Some pathologists have refused to perform an autopsy on a deceased patient who is known or suspected to harbor the CJD organism. Can you base your own decision on theirs?

Indeed knowledgeable authorities within the medical community flatly advise against embalming, including the National CJD Surveillance Unit in the United Kingdom.⁴³

Can you justify embalming a CJD case for what you charge knowing that equipment may have to be destroyed after use and additional precautions must be taken? (Which might point out the fact that embalming any case might be worth a lot more than what you might presently charge.)

These are questions that funeral home staff members should discuss prior to accepting a person deceased from CJD or suspected CJD.

The embalmer deserves to be fully informed about CJD before they make that decision. That decision should be respected and there should be no thought that there is a shirking of "professional responsibility" by electing not to attempt preparation.

© Copyright 2000, Management Associates, All Rights Reserved

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