Hospital Infection Control (Including Autopsies and Burial)

Last Updated May 25, 2011

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Isolation Precautions
Cleaning Surfaces and Instruments
Personal Protective Equipment for Workers
Other Issues
Autopsy Practices
Burial
Bibliography

Isolation Precautions

• Although people with inhalational anthrax may have had contamination of hair and clothing at the time of their exposure, residual contamination at the time of medical presentation does not appear to be of concern. Also, no secondary cases occurred among household contacts of the inhalational cases in the 2001 US outbreak.
• Standard Precautions are considered adequate for patients with inhalational and gastrointestinal anthrax, since person-to-person transmission for these forms of disease has not been reported.
• Most sources also recommend Standard Precautions for cases of cutaneous anthrax (APIC/CDC 1999, Inglesby 2002). However, person-to-person transmission rarely has been reported for patients with cutaneous anthrax; therefore, several sources have recommended that Contact Precautions be followed for patients who have draining cutaneous lesions (Swartz 2001, Weber 2001). Contact Precautions include the following:
• Place the patient in a private room, or, if a private room is not available, place the patient in a room with a patient who has an active infection with the same pathogen (ie, cohort). When a private room is not available and cohorting is not possible, a spatial separation of at least 3 ft should be maintained between the infected patient and other patients and visitors.
• Gloves should be worn when entering the room and removed before leaving the room; hands should be washed with an antimicrobial agent or a waterless hand washing agent immediately after removing gloves, and clean hands should not touch potentially contaminated items or environmental surfaces.
• Gowns should be worn when entering the room if it is anticipated that clothing will have substantial contact with the patient, environmental surfaces, or items in the room; the gown should be removed before leaving the patient's environment.
• Patient transport should be limited to essential purposes only; if the patient is transported out of the room, precautions should be maintained.
• Noncritical patient-care equipment should be dedicated whenever possible. If equipment cannot be dedicated, then it should be adequately cleaned and disinfected between patients.
• Soiled dressings should be incinerated or autoclaved.
• A study on the use of hand-hygiene agents to remove B atrophaeus (a surrogate of B anthracis) from contaminated hands demonstrated that use of a waterless hand rub containing ethyl alcohol was not effective in removing spores (Weber 2003). Conversely, hand washing with soap and water, 2% chlorhexidine gluconate, or chlorine-containing towels reduced the level of spore contamination.

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Cleaning Surfaces and Instruments

According to the CDC, the following procedures should be followed when cleaning surfaces following spills or when cleaning instruments (CDC 2001: Basic laboratory protocols for the presumptive identification of Bacillus anthracis):

• Commercially available bleach or 0.5% hypochlorite solution (a 1:10 dilution of household bleach) is considered adequate for cleaning.
• Contaminated items (eg, pipettes, needles, loops, microscope slides) should be immersed in decontamination solution until autoclaving.
• Work surfaces should be wiped down before and after use with decontamination solution.
• Spills involving fresh cultures or samples known to have low concentration of spores should be flooded with decontamination solution and soaked for 5 minutes before cleanup.
• Spills that involve samples with high concentration of spores, involve organic matter, or occur in areas of lower than room temperature (eg, refrigerators, freezers) should be exposed to decontamination solution for at least 1 hour before cleanup.
• Personnel involved in the cleanup of any spill should wear gloves, safety glasses, and a laboratory coat or gown during the cleanup process.
• Respiratory protection should be considered for spills in which a substantial aerosolization is suspected.

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Personal Protective Equipment for Workers

Information regarding personal protective equipment for first responders and others with potential occupational exposure to anthrax spores can be found on the following Web pages:

• CDC: Protecting investigators performing environmental sampling for Bacillus anthracis: personal protective equipment
• CDC: Interim recommendations for the selection and use of protective clothing and respirators against biological agents
• OSHA: Anthrax prevention and controls

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Other Issues

• One study examined biocide inactiviation of B anthracis spores in the presence of food residues (Hilgren 2007). The presence of food residues had only a minimal effect on peroxyacetic acid and H₂0₂ sporicidal efficacy, but the efficacy of sodium hypochlorite was markedly inhibited by whole-milk and egg yolk residue. Decontamination procedures should be adjusted to address situations for food-soiled surfaces.

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Autopsy Practices

• Instruments used in autopsies should be autoclaved or incinerated.
• Guidelines from the CDC indicate that Standard Precautions should be used for postmortem care. These include using a surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, a form of eye protection (eg, goggles or face shield), shoe covers, and double surgical gloves with an interposed layer of cut-proof synthetic mesh (CDC 2004: Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and case management).
• In addition, autopsy personnel should wear N-95 respirators during all autopsies, regardless of suspected or known pathogens. Powered air-purifying respirators equipped with N-95 or high-efficiency particulate air (HEPA) filters should be considered.

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Burial

• Contact with corpses should be limited to trained personnel, and routine precautions should be implemented when transporting corpses.
• According to the CDC, cremation is the preferred disposition method. If cremation is not possible, bodies should be "properly secured in a sealed container (eg, a Ziegler case or other hermetically sealed casket) to reduce the potential risk of pathogen transmission" (CDC 2004: Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and case management).
• According to WHO guidelines (WHO 1998), "In fatal cases, postmortem should be discouraged; cremation is preferable to burial where local custom permits. It is advisable for the body to be placed in an impervious body bag for transport from the place of death and preferably the body should not be extracted from the bag. Where only burial is permitted, the bagged body should be placed in a hermetically sealed coffin and buried without re-opening."
• An example of the type of system that can be used to seal remains prior to placing them in a casket for burial is the BioSeal System, produced by Barrier Products, LLC. This system utilizes a poly-aluminum foil–extruded laminate material that, when used with a heat sealer, will provide level 1 containment for all gases, fluids, vapors, and odors associated with the transport and storage of human and animal remains.

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