How To Handle Infectious Body In High Risk Cases?

Introduction

As stipulated in theStandard Operating Procedure for Potential Infectious Disease, Ministry of Health Malaysia, First Edition, 2004, high risk infectious diseases are those diseases that are classified in the Biohazard 3 and Biohazard 4 of infectious disease category.

The diseases in Biohazard 3 category include Tuberculosis, Human Immunodeficiency Virus (HIV), Hepatitis B (virus) and Hepatitis C (virus). It is caused by microorganisms that lead to serious effects towards an individual and pose a risk of spreading to the community. However, there are treatments available for the diseases in this category.

Biohazard 4 infectious diseases category are those diseases that can cause very serious effects towards human being and there is usually no effective treatment available. It poses a very high risk of spreading to the community in a large scale. Among the diseases in this category are Ebola, Marburg, Nipah Virus, Lassa and Congo-Crimea Haemorrhagic Fever.

It is very essential to adhere to the existing guidelines of the handling of infectious body in high risk cases in order to minimize the risk of transmission to health personnel and as well as to the public. Safety and prevention measures are a very serious matter in the management of high risk infectious body.

Receiving Dead Body from the Hospital Ward

Any high risk infectious body received from the ward should be placed in sealed body bag and labeled as biohazard before being transported to the mortuary. All health personnel involved in the transportation of the body from the ward to the mortuary should wear appropriate personal protective clothing in accordance with the guidelines to prevent transmission of infection.         

The health personnel should wear personal protective clothing such as face mask (N95/100), disposable body suit, plastic apron, gloves and rubber boot. In order to reduce the risk of infection, decontamination process for all the equipments used for transportation of the body will be carried out by using chlorine solution and sodium hypochlorite 70%.

Receiving Dead Body from Out of Hospital Facility (Brought in Dead [BID] Case)

The management process and the requirement of protective clothing of receiving infectious body in high risk cases from out of hospital facility are similar to the process implicated in receiving body from the hospital ward.

Storage of Body

The body received from the ward or out of hospital facility may be released as soon as possible if claimant party is immediately available. The body will be stored in the body freezer if the claimant party is unavailable and will be managed as unclaimed body.

The received body will remain in the sealed body bag and immediately stored in a 4^oC body freezer unless post mortem examination is needed. The body should be clearly labeled with identity information and marked as biohazard body. The mortuary personnel will ensure the body freezer is always in optimum condition and disinfected following the release of the body to the proper party to reduce the risk of infection.

The health personnel involved in the storage of high risk infectious body should always wear face mask (N95/100), disposable body suit, plastic apron, gloves and gum boot to avoid exposure of infection.

Post Mortem Examination

Post mortem examination will only be conducted if the consent form or Police Order (Polis 61) is obtained. The examination will be performed in a designated facility which is Biosafety Level 3 post mortem room or an upgraded Biosafety Level 2 post mortem room. This facility has a special feature with separate entrance and exit areas, separate ventilation system with negative pressure rooms, separate clinical waste management and drainage systems as well as a decontamination space for the involved personnel.

The personal protective clothing for the high risk post mortem examination  include disposable water proof body suit (biohazard suit Class A, Tyvek Dupont), disposable plastic apron, face mask (N95/100), respirator with HEPA filter, head cover with visor, two layers of glove and anti static rubber boot.

Health personnel conducting the high risk post mortem examination should be highly knowledgeable, skilled and trained in post mortem techniques as well as safety procedures. Post mortem examination will be carried out by the senior forensic pathologist and assisted by two health personnel. There should be a minimal number of personnel (not more than 3 people) involved in the examination procedure to minimize the risk of infection.

The post mortem examination will be performed on the body without removing the body from the body bag. The autopsy instrument and facility will be cleaned and disinfected upon completion of the post mortem procedure. Waste product including disposable protective clothing will be marked as high risk waste and to be managed separately from regular clinical waste.

The body is placed in a double body bag, sealed and marked as biohazard body. The body will be stored in the body freezer if there is no claimant. The body to be released immediately to the claimant will be placed in the coffin. The claimant party is not allowed to open the coffin nor proceed with embalming procedure.

Handling of Post Mortem Specimen Collection

There are two types of specimen taken if required during the post mortem examination, which are medico legal specimen and clinical specimen. The medico legal specimen is collected in accordance of Criminal Procedure Code, Act 593, Section 331, Chapter XXXII. As for the clinical specimen collection, it is conducted in accordance with the respective laboratory procedure. It is essential for the facility to be equipped with safety cabinet type 1 or 2 for the storage and handling of specimens collected.

Safety procedure during collection and management of specimen is a priority. The specimen taken should be added with appropriate preservatives and placed in a leak proof specimen container. It is labeled with the body identity information and biohazard mark. A designated box or bag is used for transportation to the relevant laboratory. The medico legal specimen will be handed over to the police and the police are required to send the specimen to respective laboratory such as the Department of Chemistry, Malaysia.

A few examples of clinical specimens collected include cerebrospinal fluid, conjunctiva swab, throat swab, pleural fluid and others. The most common medico legal specimens collected are blood and urine specimen for toxicology analysis.

Handling of Unclaimed Body

The management of unclaimed high risk body is handled according to the Standard Operating Procedure for Potential Infectious Disease, Ministry of Health Malaysia, First Edition, 2004. It is applicable only for the management of unclaimed bodies brought in dead for local burials or cremation in Malaysia. The body is stored in body bag in the freezer with identity information and biohazard label if the claimant party is unavailable.

Efforts to locate the next of kin will be initiated with the assistance of the police through mass media. If the body is not claimed within 3 days, regardless of its religion (Muslim or non-Muslim), the body shall be classified as unclaimed bodies. The body will be referred to the Islamic Religious Body or other religious body or welfare organization for the purpose of burial or cremation.

Transportation of Body to the Other State or Country

The transportation of high risk body to the other state or country is subjected to the Prevention and Control of Infectious Diseases Act 1988, Act 342, in which it stated that any transportation of human remains and its part into or out of Malaysia requires the permission of the Ministry of Health Malaysia.

The next-of-kin are required to notify and obtained a letter of permission from the Ministry of Health Malaysia to transport the body to the desired location. The application of the next of kin should comply with the regulations, guideline and other conditions imposed by the recipient country.

Letter of permission will be granted if the supporting document such as Certified of Death, Burial Permit and Embalming Certificate (if related) is complete and the casket used for transportation is in good condition.

The handling of the transportation of high risk body to the other state or country is manage in accordance to the Garis Panduan Pengimportan atau Pengeksportan Mayat Atau Mana-mana Bahagiannya, Edisi Pertama, 2006. The high risk body should be placed in a body bag prior to moving it into the specified coffin.

The coffin used for the transportation of the body contains a covered air tight box made from zinc. The body will be placed in the zinc box, closed and all parts of the box are sealed with sealant. The coffin will be closed and fastened after ensuring that the zinc box is leak proof and tightly closed.

As declared by the airlines regulation, any human remains to be transported via airplane, the casket used should be packed properly with appropriate cloth material. Bodies should be buried or cremated as soon as possible after arriving at the desired destination. Any equipment or vehicles used in the body delivery process will be decontaminated to prevent the spread of infectious diseases.

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