The Ebola virus has only killed one person on U.S. soil, but
the Centers for Disease Control and Prevention has issued protocols for how to
deal with victims’ bodies to avoid new infections.
Health care workers in the United States are not the only ones confused over evolving government directions for treating Ebola patients.
Funeral directors, whose work and personal safety also could be affected in the event of an outbreak, are puzzling over federal edicts for handling the dead that conflict with long-standing practices and state laws.
"Everyone's taking it pretty seriously," said Robert Fells, a lawyer who directs the International Cemetery, Cremation and Funeral Association. "Our people will be on the front lines when and if there are any deaths from Ebola."
The Centers for Disease Control and Prevention recommends a series of precautions that it says are aimed at safety for all who, by virtue of their jobs, could come into contact with those carrying the disease.
Among the protocols: The dead should get double-bagged, and buried or cremated as soon as possible after death. Autopsies are to be avoided, and embalming is ruled out. No open caskets or visits for family members of the deceased, even to confirm identification.
Funeral home workers are not to wash the body, a typical and important rite to practitioners of some religious faiths. Nor are they to remove tracheal tubes or catheters, let alone implanted devices such as pacemakers or defibrillators that can explode in a crematory furnace.
The guidelines run counter to mandatory waiting periods between death and cremation — a safeguard on multiple levels, including to make sure that the right person is being cremated. They also conflict with the industry's safety standards for cremation and practices meant to ensure the dead are treated with dignity.
"There is a lot of talk in the industry about this," said John McQueen, the owner of Anderson-McQueen Funeral Home in St. Petersburg and the recently elected president of the board of the Academy of Professional Funeral Service Practice.
A loose network of funeral and cremation providers in Tampa Bay, as well as professional associations nationwide, have been quizzing and sending CDC updates to one another in recent months.
Funeral industry representatives note that they are already well versed in responding to disasters, as a surge of Ebola deaths would certainly represent. And they've handled bodies struck down by contagious diseases and other disasters since the profession came into being.
"This is no different from any other health care worker," said Tom Ralph, a Plantation funeral home owner and a board member of FEMORS, or the Florida Emergency Mortuary Response System. "Funeral directors have been doing this for centuries in some fashion or another."
In Florida, some funeral workers remain on call for FEMORS, a watch list. Because that system was in place, crews were ready to handle the remains of the 110 people who died in 1996 on Mother's Day, when ValuJet Flight 592 crashed into the Everglades.
At the same time, the CDC wants funeral workers to be prepared because of the nature of Ebola itself, should an outbreak threaten. The disease is at its most potent when its victim has died, often preceded by substantial leaking of body fluids that continues after death.
"Bleeding is abundant, but this is also when the viral load is the biggest," said Tarik Jasarevic, a spokesman with the World Health Organization in Geneva.
That dynamic, coupled with African funeral customs of kissing or touching corpses, has contributed to the spread of Ebola in Guinea, Sierra Leone and Liberia, leading some to refer to certain funerals as "superspreaders" of the virus. A study published in the Sept. 12 issue of Science linked 78 Ebola cases to 14 women who had attended a funeral in Sierra Leone.
An Aug. 20 CDC document says that when an Ebola patient dies, workers should wrap the body in a plastic shroud, slip the wrapped body into a body bag of a predetermined thickness, disinfect the bag, then deposit it into another body bag and disinfect that one, too.
From that point, no one sees the face of the deceased again.
"We do a visual identification of the remains to make sure, 'Hey, we cremated an 85-year-old woman,'" McQueen said. "I'm guessing we won't be doing that in this process."
The body of Thomas Duncan, the only person to have died of Ebola on U.S. soil, was cremated by Texas health authorities according to these protocols.
In another point of contention, the guideline calling for immediate disposal of bodies places cremation providers in a legal dilemma. Florida and other states require a 48-hour waiting period before a body can be cremated. The holding time gives funeral homes enough time to procure a death certificate and notify any remaining family members.
"What do you do?" said Keenan Knopke, owner of Curlew Hills Memory Gardens in Clearwater. "Do you do what the CDC recommends you do, or do you do what the state law will discipline you on?"
Meanwhile, crematory operators consider removing battery-operated devices such as pacemakers and defibrillators from the deceased an important safety precaution. Explosions of those devices have damaged cremation chambers and injured workers.
The CDC cautions against removing any such devices from Ebola victims, posing another dilemma.
"Is the risk of explosion greater than the risk of exposure to bodily fluids?" said Barbara Kemmis, executive director of the Cremation Association of North America. "I would never tell a CANA member never to remove a pacemaker because I don't know which risk is greater."
For those who are buried, the CDC specifies that health or mortuary workers should deposit the shrouded and wrapped bodies in a "hermetically sealed casket."
Strictly speaking, there is no such thing as a hermetically sealed or airtight casket. The CDC is likely referring to Ziegler transfer cases, galvanized steel shipping containers used for transporting bodies over long distances, said Mark Risch, a St. Petersburg warehouse manager for Aurora Casket Co. The cases do not allow air in or out. Risch said he normally stocks about 20 of them a year.
"But with this Ebola scare I have purchased a couple more, just in case," Risch said.
Fells, of the International Cemetery, Cremation and Funeral Association, asked the CDC to clarify its guidelines. Although the CDC did not reply directly, Fells told the Times that other federal government sources relayed his questions to the agency.
On exploding pacemakers, he said, "The answer was basically in those cases, use the option to bury."
The CDC's recommendations do not carry the force of law, and the agency would evaluate any Ebola death on a case-by-case basis, spokeswoman Melissa Brower said.
As for the waiting period and other issues raised by providers, Brower said the agency has created "a mortuary working group" to answer such questions.
In the meantime, funeral professionals are hoping that their preparations for Ebola will turn out to be unnecessary.
"You've got to be extra vigilant and pay attention," Knopke said. "If you've got to trust something I guess it's got to be the government, good or bad."
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