Abstract

In the wake of disasters, the lack of information on how to handle and dispose of corpses leads the professionals involved in emergency operations to uncertainty about associated risks and safety precautions. The article seeks to establish the risks of the etiologic agents involved in Brazilian mortality due to infectious diseases and identify and discuss the main protection measures for professionals involved in handling of corpses in disaster situations. It involved a survey of deaths by infectious diseases in Brazil between 2005 and 2010, using data from the Mortality Information System. Of the 171,223 deaths analyzed, the pathogens leading to the greatest number of deaths were: HIV, Mycobacterium tuberculosis and Trypanosoma cruzi. 59% belonged to risk class 3 and 40.6% to risk class 2. Eight deaths were caused by risk class 4 pathogens, which represent high risk. The professionals involved in the handling of corpses may be exposed to chronic risks, such as viruses transmitted via blood, gastrointestinal infections and tuberculosis. These findings indicate the importance of investment in the preparation of measures to reduce the risk of infection associated with the handling of corpses.

Corpse; Disasters; Risk; Exposure to biological agents; Public health

Resumo

Após os desastres, a falta de informações claras sobre como gerenciar a disposição dos cadáveres, resultam em incertezas entre os profissionais envolvidos no atendimento emergencial, de quais são os riscos associados e as medidas de segurança no manejo dos corpos. O artigo objetiva determiner o risco dos agentes etiológicos envolvidos na mortalidade brasileira por doenças infecciosas, identificar e discutir as principais medidas de proteção para os profissionais envolvidos no manejo de cadáveres em situações de desastres. Levantamento dos óbitos por doenças infecciosas, no Brasil, de 2005 a 2010, utilizando-se os dados do Sistema de Informações sobre Mortalidade. Dos 171.223 óbitos analisados, os patógenos causadores de maior número de mortes foram: HIV, M. tuberculosis e T cruzi. Dos agentes, 59% pertencem à classe de risco 3 e 40,6% à classe 2. Oito óbitos identificados foram causados por patógenos da classe 4, que representam alto risco. Os profissionais envolvidos no manejo de corpos podem estar expostos aos riscos crônicos, como os vírus transmitidos pelo sangue, infecções gastrointestinais e tuberculose. Estes resultados demonstram a importância no investimento na elaboração de medidas para reduzir o risco de infecção associada ao manejo de cadáveres.

Cadáver; Desastres; Risco; Exposição a agentes biológicos; Saúde pública

Introduction

The devastating phenomena caused by disasters are part of history. The social groups affected suffer the loss of many lives, economic or environmental losses exceeding its ability to respond, with repercussions on economy, exceeding its (ability to respond) responsiveness¹1. United Nations International Strategy for Disaster Reduction (UNISDR). Terminology on Disaster Risk Reduction. Geneva: UNISDR; 2009..

Disasters are the result of combination of exposure to a hazard, vulnerabilities and society’s inability to control or deal with consequences.These events have different amplitude in their impacts, however, the social commotion, the possibility of disease occurrence and the impacts on the affected population’s mental health are common to all disasters.

The Emergency Events Databaseshows that between 1900-2010, the highest number of natural disasters occurred on the Asian continent. However, the highest numbers of deaths were caused by the 7.0 Richter-scale magnitude earthquake that occurred in Haiti (2010), which caused over 222,570 deaths and made 3,700,000 people homeless, and the earthquake followed by tsunami in Indonesia (2004) with 165,708 deaths and 532,898 homeless²2. World Health Organization. Collaborating Centre for Research on the Epidemiology of Disasters [Internet]. The International Disaster Database. [cited 2013 Jun 27]. Available from: http://www.emdat.be
http://www.emdat.be... .

In Brazil, during 1970/2008 there was a rise in the incidence of climactic events involving extreme temperatures and floods, causing the death of more than 6,000 people and damages of 10 billion dollars²2. World Health Organization. Collaborating Centre for Research on the Epidemiology of Disasters [Internet]. The International Disaster Database. [cited 2013 Jun 27]. Available from: http://www.emdat.be
http://www.emdat.be... . A flood, followed by landslides, occurred in 2011, in the mountain region of Rio de Janeiro state, for example, hit 18 municipalities, leading to 918 deaths and 31,399 homeless and displaced people³3. Freitas CM, Carvalho ML, Ximenes EF, Arraes EF, Gomes JO. Vulnerabilidade socioambiental, redução de riscos de desastres e construção da resiliência: lições do terremoto no Haiti e das chuvas fortes na Região Serrana, Brasil. Cien Saude Colet 2012; 17(6):1577-1586..

Most disasters, except for gradual floods, are unpredictable, sudden and normally violent phenomena, occasioning deaths by traumas, drownings and burns, among others. They cause a sudden presence of corpses, causing stress in the society and representing a social, sanitary, legal and organizational problem, and leads to a collective disposal through mass burials or incineration. The World Health Organization emphasizes there is no evidence that the presence of corpses increases the risk of epidemics⁴4. World Health Organization. Management of dead bodies after disasters: a field manual for first responders. Washington: PAHO; 2006._.

Disease transmission requires the presence of an agent, exposure to that agent and a susceptible host. To determine the risk involved in the management of dead bodies following disasters is necessary to consider these elements.

Following large disasters, the lack of clear information on how to manage the dead, leads to uncertainty among professionals involved in emergency care. The associated risks; biosafety principles, including containment principles and precautions; and how to handle bodies safely, are informations unclear. Thus, situations that may represent risk are in the field of biosafety, which establishes principles and strategies based on risk assessment⁵5. Gershon RR, Vlahov D, Escamilla-Cejudo JA, Badawi M, McDiarmid M, Karkashian C, Grimes M, Comstock GW. Tuberculosis risk in funeral home employees. J Occup Environ Med 1998; 40(5):497-503.

6. Healing T, Hoffman P, Young S. The infection hazards of human cadavers. Commun Dis Rep CDR Rev 1995; 5(5):61-68.

7. Gershon RR, Vlahov D, Farzadegan H, Alter MJPH. Occupational risk of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infections among funeral service practitioners in Maryland. Infect Control Hosp Epidemiol 1995; 16(4):194-197.

8. Goyet CV. Stop Propagating disaster myths. Lancet 2000; 356(9231):762-764.

9. Centers for Disease Control and Prevention. Hepatitis C virus infection among firefighters, emergency medical technicians, and paramedics. Morb Mortal Wkly Rep 2000; 49(29):660-665.

10. Curtis V, Biran A. Dirt, disgust, and disease. Is hygiene in our genes? Perspect Biol Med 2001; 44(1):17-31.

11. Rischetelli G, Harris J, McCauley L, Gershon RR, Guidotti T. The risk of acquiring hepatitis B or C among public safety workers. Am J Prev Med 2001; 20(4):299-306.^-1212. Morgan O. Infectious disease risks from dead bodies following natural disasters. Pan Am J Public Health 2004; 15(5):307-312..

There are some pathogens in corpses that may represent risks; such as Mycobacterium tuberculosis, hepatites B and C virus, Vibrio cholerae, HIV, hemorrhagic fever virus and príons¹³13. Weed I, Baggenstoss A. The isolation of pathogens from tissues of embalmed human bodies. Am J Clin Pathol 1951; 21(12):1114-1120.

14. Brown P, Gibbs CJ, Gajdusek DC, Cathala F, LaBauge R. Transmission of Creutzfeldt-Jakob disease from formalin-fixed, paraffin embedded human brain tissue. N Engl J Med 1986; 315(25):1614-1615.

15. Roth D, Fernandez JA, Babischkin S, De Mattos A, Buck BE, Quan S, Olson L, Burke GW, Nery JR, Esquenazi V, Schiff ER, Miller J. Detection of hepatitis C virus infection among cadaver organ donors: Evidence for low transmission of disease. Ann Intern Med 1992; 117(6):470-475.

16. De Craemer D. Postmortem viability of human immunodeficiency virus-implications for the teaching of anatomy. N Eng J Med 1994; 331(19):1315.

17. Kappel TJ, Reinartz JJ, Schmid JL, Holter JJ, Azar MM. The viability of Mycobacterium tuberculosis in formalin fixed autopsy tissue: Review of literature and brief report. Hum Pathol 1996; 27(12):1361-1364.

18. Cattaneo C, Nuttall PA, Molendini LO, Pellegrinelli M, Grandi M, Sokol RJ. Prevalence of HIV and hepatitis C markers among a cadaver population in Milan. J Clin Pathol 1999; 52(4):267-270.^-1919. Demiryürek D, Bayramoglu A, Ustacelebi S. Infective Agents in Fixed Human Cadavers: A Brief Review and Suggested Guidelines. Anat Rec (New Anat) 2002; 269(4):194-197..To determine the risk, it is necessary to consider that some victims may be carriers of infections and, therefore, they will require special care. It must be noted, however, that the biological agents involved in the natural putrefaction process are not pathogenic. Besides, the human body is a host of many biological agents, some of them are pathogenic, which mostly do not survive more than 48 hours after death. It is in this time window where there is a greater likelihood of infections acquired by improper handling of corpses. Therefore, we can state that the disaster victims host pathogens that are circulating in the local population, so the risk is similar to handling patients in health care areas⁴4. World Health Organization. Management of dead bodies after disasters: a field manual for first responders. Washington: PAHO; 2006.^,1212. Morgan O. Infectious disease risks from dead bodies following natural disasters. Pan Am J Public Health 2004; 15(5):307-312.^,2020. Goyet VC. Lasenfermedadestransmisibles y lavigilancia epidemiológica ensituaciones de desastres naturales. Bol Oficina Sanit Panam 1980; 89(4):353-359..

This study aims to analyze the etiologic agents involved in brazilian mortality by infectious diseases, in order to identify the risk and discuss the main protection measures necessary for the professionals involved in corpse handling in disasters.

Methodology

To reach the objectives was carried a research using the Brazilian Health Ministry’s Mortality Information System (SIM) data²¹21. Brasil. Ministério Saúde (MS). Departamento de Informática do SUS - DATASUS. Sistema de Informação sobre Mortalidade. [homepage na Internet]. [acessado 2012 dez 15]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0901&item=1&acao=26&pad=31655
http://www2.datasus.gov.br/DATASUS/index... , which uses the Death Declaration standardized nationally. The registration of causes of death is based on the 10th edition’s International Classification of Diseases (ICD 2008), implemented since 1996 by WHO.

The ICD-10 presents twelve chapters, one of them is related to infectious and parasitic diseases. It provides codes for classifying diseases. To each state of health, a single category with a corresponding alphanumeric code contains up to four characters, consisting of a letter followed by three numbers. In the studied chapter the coding starts in A00 until B99.

The SIM’s data was obtained using the Oracle 10G software.

The study population was represented by the deaths in Brazil due to the infectious diseases contained in chapter I of the ICD. The study covered the period 2005/2010 (six years).

The inclusion criteria used was the deaths caused by infectious diseases. The exclusions criteria were: deaths from diseases with etiologic agents that could not be identified; deaths from unspecified diseases and deaths from diseases which could have more than one etiologic agent involved.

After this, the etiologic agent was identified to be classified according to the brazilian Health Ministry’s risk group classification²²22. Brasil. Ministério da Saúde (MS). Comissão de Biossegurança em Saúde. Classificação de risco dos agentesbiológicos. 2ª ed. Brasília: MS; 2010..

For descriptive analysis, the method of absolute frequency distribution was employed. The data was analyzed using the program SPSS 16.0.

All data used in this analysis are public domain and preserve the individuals’ identity.

Results

The study found 282,187 deaths from infectious diseases. 110,964 cases (39.322%) are excluded.The Table 1 shows the pathogens responsible for diseases with more than 500 deaths and their risk.

The region with the highest number of reported deaths is the Southeast, with 82,969 cases (48.456%), followed by the Northeast with 37,464 (21.880%) and the South, Center-West and North regions with 25,604 (14.953%), 14,666 cases (8.565%) and 10,520 cases (6.144%), respectively.

Among the pathogens causing diseases with more than 1,000 deaths were:

1. HIV/AIDS – 69,642 deaths: Southeast region (35,112), South region (15,125), Northeast region (10,873), North region (4,346) and Center West (4,186).

2. Mycobacterium tuberculosis – 31,435 deaths: Southeast region (13,907), Northeast region (10,612), South region (3,176), North region (2,271) and Center-West region (1,469);

3. Trypanosoma cruzi – 29,284 deaths: Southeast region (14,922), Center-West region (6,249), Northeast region (6,079), South region (1,603) and North region (431).

In many countries, including Brazil, infectious agents are categorized by risk groups based on their relative risk. Figure 1 presents the number of deaths caused by infectious diseases, according to the risk group of the etiologic agent.

There are no deaths from diseases caused by risk group 1 agents. There is variation between mortality from diseases whose etiological agents belong to the risk group 2 (n: 69,591) and 3 (n: 101,624), with the predominance of deaths by risk group 3 agents.

Among the risk group 2 pathogens in that caused the highest number of deaths are the agents for Chagas disease (17.102%), Hepatitis C (6.297%), erysipelas (2.786%), Hepatitis B (1.935%), meningococcal meningitis (1.548%), dengue (1.303%), leishmaniasis (1.229%) and schistosomiasis (1.195%).

From the analysis of the distribution of deaths and risk group of the agent involved in the infection, shown in Figure 1, there is an increase in deaths from 2008 through 2010.

The states that presented the highest number of death caused by risk group 2 agents were São Paulo (25.394%), Minas Gerais (14.920%), Bahia (8.131%), Rio de Janeiro (7.006%) and Goiás (6.890%) (Figure 2).

The largest numbers of deaths due to diseases caused by risk group 3 agents were observed in the states of São Paulo (25.031%), Rio de Janeiro (14.774%) and Rio Grande do Sul (10.192%). Another important factor is the state of Pará with 0% of deaths (Figure 3).

In this group are HIV/AIDS (40.673%), Mycobacterium tuberculosis (18.459%) and other lower incidence but high epidemiological relevance, such as hantavirus (0.116%) and Histoplasma capsulatum (0.128%).

Among the arboviruses belonging to risk group 3, which constitute a public health problem, due to the morbidity and/or mortality, we identified: Yellow Fever virus (37 deaths), VEE (01), Chikungunya virus (03) and West Nile virus (01). It also identified 8 deaths caused by group 4 agents: 07 for Junin virus (71.428% in the Northeast) and 01 for Crimean Congo hemorrhagic fever virus (Southeast) (Figure 4).

Discussion

The Southeast region presented the highest number of notifications (48.456%), because it has the highest population density. There is a vertical increase in the magnitude of deaths coverage in the north-south direction. The under-notification rates for deaths in the North and Northeast region is due to the fact these regions have the most precarious development indicators in Brazil²³23. Paes NA. Qualidade das estatísticas de óbitos por causas desconhecidas dos Estados brasileiros. Rev Saude Publica 2007; 41(3):436-445.. However, it is important to point out as limitation of this study the possibility of errors in the diagnosis of diseases and errors related to the quality of information, in the record of the underlying death cause, contained in the Death Declaration.

The Northeast region had the highest number of deaths caused by Leishmania infantum, Schistosoma mansoni and M. leprae; that are representative of the socioeconomic conditions. This region has the lowest average total home earnings (nominal) per capita²⁴24. Instituto Brasileiro de Geografia e Estatística (IBGE). Indicadores Sociais Municipais. Uma análise dos resultados do universo do Censo Demográfico 2010. Rio de Janeiro: IBGE; 2011..

The etiologic agents are classified according to their risk, in order to relate them to biosafety recommendations. This classification is based on the interaction of criteria like: individual, community and environment risk; mode of transmission; pathogenicity; genetic alteration; endemicity; infective dose; availability prophylaxis and effective treatment. The consequences of the infections reflect the complexity of these interactions.

The risk associated with new agents of high lethality, which may turn into pandemic events, is a growing concern. Sabia virus, Oropouche virus and zoonotic strains of Hantavirus isolated in São Paulo, are among the most relevant pathogens.

Another factor for risk assessment is related to infections that could have been treated effectively with antibiotics, such as: M. tuberculosis and Staphylococcus aureus, which have become resistant.

The classification categorizes biological agents into 4 groups, increasing by degree of containment and complexity of protection level.

The pathogens classified as risk group 1 cause a low or practically nonexistent individual risk.

The risk group 2 agents can cause human disease and might be a hazard to employees. Effective prophylaxis and treatment are often available, and the risk of dissemination is limited. Trypanosoma cruzi is one of these agents of importance related to number of deaths in Brazil (n: 29,284), despite the national program for the control be one of the greatest successes of the public health system. This number is due to the disease’s long latency period; 3,5 million individuals are still chronically infected²⁵25. Barreto M, Teixeira MG, Bastos FI, Ximenes RAA, Barata RB, Rodrigues LC. Sucessos e fracassos no contole de doenças infecciosas no Brasil: o contexto social e ambiental, políticas, intervenções e necessidades de pesquisa. Lancet 2011; 5:47-60..

We highlight the importance of the deaths (18) caused by transmissible spongiform encephalopathies, combination of deaths caused by prions and Creutzfeldt-Jakob disease. Brazil currently ranks these agents as belonging to risk group 2. These occurrences are important due to the fact these agents with no genetic material (DNA and RNA), composed only of protein (PrPsc), produce diseases in humans and animals and are resistant to most chemical or disinfection methods routinely practiced in brazilian hospitals and laboratories.

Risk group 3 agents can cause severe or lethal human diseases represents a serious hazard to directly exposed people, because of the potential for aerosol transmission and risk of dissemination.

Deaths from HIV/AIDS present an growth of 3% a year starting in 2005. Tuberculosis appeared as the second most important cause of death, with steady number of deaths per year. Together, they represent 99.461% of the group 3 agents and rose the total quantity of deaths caused by these pathogens.These diseases are still a public health problem in several of Brazil’s regions, despite the considerable proportion (13%) of health care resources, which continues to be spent on disease control²⁵25. Barreto M, Teixeira MG, Bastos FI, Ximenes RAA, Barata RB, Rodrigues LC. Sucessos e fracassos no contole de doenças infecciosas no Brasil: o contexto social e ambiental, políticas, intervenções e necessidades de pesquisa. Lancet 2011; 5:47-60..

HIV/AIDS deaths have decrease in the Southeast region, although it is the region with the highest number of notifications (48.480%). North, Northeast and South regions present an upward trend and the Center-West region is the most stable.

Tuberculosis, on the other hand, is a high-morbidity endemic disease that manifests higher death risks among the adult population. Sequels of injuries take years to develop, often in a subclinical manner. There are great regional differences in tuberculosis mortality, with higher levels in states with a greater prevalence of HIV/AIDS, such as Rio de Janeiro and São Paulo, and in states with limited access to health care services, like states in the Amazon region. It was observed that there is subnotification of deaths from diseases with compulsory notification, including the arboviruses in the North region states: Acre, Roraima, Rondonia, Amapá and a total absence of events in Pará revealing a deficiency in the regional system of epidemiological surveillance. It is relevant, since there are some types of viruses, such as the arbovirus that despite they have a wide geographical distributed in Brazil, they predominate in the tropics, where there are favorable ecological conditions. A great number of different types of arboviruses were identified in the brazilian amazon and they have been proved to be pathogenic, although the virulence of most of these viruses is still unknown²⁶26. Vasconcelos PFC, Travassos da Rosa APA, Rodrigues SG, Travassos da Rosa ES, Degallier N, Travassos da Rosa JFS. Inadequate management of natural ecosystem in the Brazilian Amazon Region results in the emergence and reemergence of arboviruses. Cad Saude Publica 2001; 17(Supl.):155-164..

Group 4 agents has epidemiological relevance and represents a high risk, due to degree of dissemination, transmissibility, lethality or causative of emerging diseases whose transmission mechanism is unknown. Until now there are no effective treatment and prevent measures, demonstrating the relevance of the eight deaths caused by agents of this group.

Corpses and disasters

The sudden presence of a greater number of corpses in areas affected by disaster can cause fear in the population over disease outbreaks; however, the deaths are normally caused by traumas, burns, among others. There is few evidence that corpses may constitute a risk in areas that are not endemic for specific diseases. However, the human body hosts biological agents, some of which are pathogenic, so disaster victims host pathogens that are circulating in the population. Thus, the risk associated with corpse handling is similar to the healthcare service. In order to determine the risks it is necessary to have an adequate understanding of the epidemiological structure of the microbial agents, including infection sources and their means of transmission. These factors are determinant in preventing and reducing contamination risk while working. If we consider the infection a result of a multifactor interaction, it is possible to characterize the risks that corpses represent after a natural disaster.

Some infections are transmitted from one person to another, whether sick or carrier; however, the disease severity does not necessarily imply in risk to other person. A patient with a mild infection can disseminate the agent to more people than if he has in a serious condition, showing enough symptoms that could justify his hospitalization or isolation. There are carriers, who eliminate infectious agents, but do not present signs of disease, and there are those who are convalescing and continue eliminating the agent of the infection. These people pose a risk to others, because they cannot always be recognized as carriers, which makes them a potential source of infection.

The professionals are responsible for seeking information about the risks they can be exposed to in the region where the disaster occurred, considering the endemic zone of diseases or the complexity that exists in the location where certain cases are more frequent. Then they be able to identify the precautions.

The scientific evidence based on examination of diseases, that could represent a risk to public health in the presence of corpses, suggests that a set of specific criteria is needed: a large number of corpses carrying disease in endemic areas; a wide dissemination of the disease in the area; a long survival time of the etiologic agent in the human or animal body or in the environment after the host’s death; and the necessary environmental conditions for the propagation of diseases²⁷27. Sazzad HM, Hossain MJ, Gurley ES, Ameen KM, Parveen S, Islam MS, Faruque LI, Podder G, Banu SS, Lo MK, Rollin PE, Rota PA, Daszak P, Rahman M, Luby SP. Nipah virus infection outbreak with nosocomial and corpse-to-human transmission, Bangladesh. Emerg Infect Dis 2013; 19(2):210-217.. These criteria often need to be simultaneous to constitute a risk to public health. Removing any of these criteria may result in a significant risk reduction.

The agents associated with disease transmission via corpse manipulation include the blood-borne viruses (HIV, HBV, HCV, HTLV-1), gastroenteric pathogens (Salmonella, Shigella, Campylobacter enteritis, V. cholerae, E. coli, rotavirus, norovirus, HAV and enteric adenoviruses), parasites (Giardia, Cryptosporidium) and air transmission agents (Mycobacterium tuberculosis)⁴4. World Health Organization. Management of dead bodies after disasters: a field manual for first responders. Washington: PAHO; 2006.^,66. Healing T, Hoffman P, Young S. The infection hazards of human cadavers. Commun Dis Rep CDR Rev 1995; 5(5):61-68.^,1212. Morgan O. Infectious disease risks from dead bodies following natural disasters. Pan Am J Public Health 2004; 15(5):307-312.^,2828. Sack RB, Siddique AK. Corpses and the spread of cholera. Lancet 1998; 352(9140):1570.^,2929. Conly JM, Johnston BL. Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005; 16(5):269-270.. However, we must consider that, although some diseases are contagious, their etiologic agents cannot survive more than 48 hours in corpses⁶6. Healing T, Hoffman P, Young S. The infection hazards of human cadavers. Commun Dis Rep CDR Rev 1995; 5(5):61-68.^,1212. Morgan O. Infectious disease risks from dead bodies following natural disasters. Pan Am J Public Health 2004; 15(5):307-312.. This is the period of greatest likelihood of infections. But there are some agents, including blood-transmitted viruses (e.g. Sabia virus, Ebola virus, Marburg virus and CCHF virus) and enteric pathogens (e.g. V. cholerae), which can remain viable for some time in the body. In this case, the risk of transmission from corpses is possible, and specific precautions are needed¹²12. Morgan O. Infectious disease risks from dead bodies following natural disasters. Pan Am J Public Health 2004; 15(5):307-312.^,2828. Sack RB, Siddique AK. Corpses and the spread of cholera. Lancet 1998; 352(9140):1570.

29. Conly JM, Johnston BL. Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005; 16(5):269-270.^-3030. Kouadio IK, Aljunid S, Kamigaki T, Hammad K, Oshitani H. Infectious diseases following natural disasters: prevention and control measures. Expert Rev Anti Infect Ther 2012; 10(1):95-104..

In catastrophes there is a higher risk of percutaneous injuries involving perforating or cutting materials during the handling of rubble, hardware, woodwork and even bone and teeth fragments from mutilated bodies, which may cause the transmission of diseases by blood. Among the major pathogens responsible for the contamination of professionals during percutaneous accidents are HIV, HBV and HCV⁷7. Gershon RR, Vlahov D, Farzadegan H, Alter MJPH. Occupational risk of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infections among funeral service practitioners in Maryland. Infect Control Hosp Epidemiol 1995; 16(4):194-197.^,3131. Centers for Disease Control and Prevention. Update: U.S. Public Health Service Guidelines for the Management of Occupational Exposure to HBV, HCV, and HIV. Recommendations for Postexposure Prophylaxis. Morb Mortal Wkly Rep 2001; 50(RR11):1-42.^,3232. Nishide VM, Benatti MCC, Alexandre NMC. Ocorrência de acidente do trabalho em uma unidade de terapia intensiva. Rev Lat Am Enferm 2004; 12(2):204-211..

This study found that 40.643% of the deaths was caused by HIV. As the virus may be present in corpses at the same incidence percentage, HIV represents a high risk for professionals involved in disasters. In addition, we must consider that HIV remains viable in the blood and in the pleural and pericardial fluids up to 16 days post-mortem, if the body is stored at low temperatures (2⁰C)⁴4. World Health Organization. Management of dead bodies after disasters: a field manual for first responders. Washington: PAHO; 2006.^,1919. Demiryürek D, Bayramoglu A, Ustacelebi S. Infective Agents in Fixed Human Cadavers: A Brief Review and Suggested Guidelines. Anat Rec (New Anat) 2002; 269(4):194-197.^,2929. Conly JM, Johnston BL. Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005; 16(5):269-270.. The HIV has been isolated in bone fragments, spleen, brain, bone medulla and lymph nodes 6 days after post-mortem⁴4. World Health Organization. Management of dead bodies after disasters: a field manual for first responders. Washington: PAHO; 2006.^,1919. Demiryürek D, Bayramoglu A, Ustacelebi S. Infective Agents in Fixed Human Cadavers: A Brief Review and Suggested Guidelines. Anat Rec (New Anat) 2002; 269(4):194-197.^,2929. Conly JM, Johnston BL. Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005; 16(5):269-270.^,3333. Ho DD, Rota TR, Schooley RT, Kaplan JC, Allan JD, Groopman JE, Resnick L, Felsenstein D, Andrews CA, Hirsch MS. Isolation of HTLV-III from cerebrospinal fluid and neural tissues of patients with neurologic syndromes related to the acquired immunodeficiency syndrome. N Engl J Med 1985; 313(24):1493-1497.

34. Nyberg M, Suni J, Haltia M. Isolation of human immunodeficiency virus (HIV) at autopsy one to six days postmortem. Am J Clin Pathol 1990; 94(4):422-425.

35. Douceron H, Deforges L, Gherardi R, Sobel A, Chariot P. Long-lasting postmortem viability of human immunodeficiency virus: a potential risk in forensic medicine practice. Forensic Sci Int 1993; 160(1):61-66.

36. Burton JL. Health and safety at necropsy. J Clin Pathol 2003; 56(4):254-260.^-3737. Mahajan A, Seema, Gandhi D. Human Cadavers-Review of Infectious Diseases. Int J Basic and App Med Sciences 2011; 1(1):66-69. and detected, in 2006, after 6 days among the tsunami corpses in Indonesia⁴4. World Health Organization. Management of dead bodies after disasters: a field manual for first responders. Washington: PAHO; 2006.. It is important to note that the corpses infected by HIV are often coinfected with other agents³⁸38. Escombe AR, Oeser C, Gilman RH, Navincopa M, Ticona E, Martinez C, Caviedes L, Sheen P, Gonzalez A, Noakes C, Moore DA, Friedland JS, Evans CA. The Detection of Airborne Transmission of Tuberculosis from HIV-Infected Patients, Using an In Vivo Air Sampling Model. Clin Infect Dis 2007; 44(10):1349-1357..

The risk of chronification of the HBV, in Brazil, varies between 5-10% and for the HCV, between 60-90%³⁹39. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Doenças Infecciosas e Parasitárias. Brasília: MS; 2010.. This percentage is considered high for professionals exposed to blood.

HBV and HCV transmission is similar to HIV. However, HBV unlike HIV is capable of surviving in stains of dried blood or other dry body fluids for 7 days. HBV is highly infectious agent and transmission can occur after exposure to extremely low volumes of infected blood; but the occupational risk of HBV is low, largely due to preexposure vaccination. In contrast, HCV, less infectious than HBV, has a higher occupational risk due to the inexistence of prophylactic measures³⁶36. Burton JL. Health and safety at necropsy. J Clin Pathol 2003; 56(4):254-260.^,3737. Mahajan A, Seema, Gandhi D. Human Cadavers-Review of Infectious Diseases. Int J Basic and App Med Sciences 2011; 1(1):66-69.^,4040. Hostiuc S, Curca GC, Ceausu M, Rusu MC, Niculescu E, Dermengiu D. Infectious risks in autopsy practice. J Leg Med 2011; 19(3):183-188..

The resurgence of tuberculosis, especially in HIV positive patients and the emergence and growth of the number of cases of extensively drug-resistant strains reinforce the importance of this disease for professional involved in the management of dead bodies⁶6. Healing T, Hoffman P, Young S. The infection hazards of human cadavers. Commun Dis Rep CDR Rev 1995; 5(5):61-68.^,1919. Demiryürek D, Bayramoglu A, Ustacelebi S. Infective Agents in Fixed Human Cadavers: A Brief Review and Suggested Guidelines. Anat Rec (New Anat) 2002; 269(4):194-197.^,3636. Burton JL. Health and safety at necropsy. J Clin Pathol 2003; 56(4):254-260.^,4141. Collins CH, Grange JM. Tuberculosis acquired in laboratories and necropsy rooms. Commun Dis Public Health 1999; 2(3):161-167.

42. Sterling TR, Pope DS, Bishai WR, Harrington S, Gershon RR, Chaisson RE. Transmission of mycobacterium tuberculosis from a cadaver to an embalmer. N Engl J Med 2000; 342(4):246-248.^-4343. Sharma BR, Reader MD. Autopsy Room: A Potential Source of Infection at Work Place in Developing Countries. Am J Infect Dis 2005; 1(1):25-33.. The risk of contamination with M. tuberculosis among professionals who handle corpses is real⁵5. Gershon RR, Vlahov D, Escamilla-Cejudo JA, Badawi M, McDiarmid M, Karkashian C, Grimes M, Comstock GW. Tuberculosis risk in funeral home employees. J Occup Environ Med 1998; 40(5):497-503.^,1717. Kappel TJ, Reinartz JJ, Schmid JL, Holter JJ, Azar MM. The viability of Mycobacterium tuberculosis in formalin fixed autopsy tissue: Review of literature and brief report. Hum Pathol 1996; 27(12):1361-1364.^,3636. Burton JL. Health and safety at necropsy. J Clin Pathol 2003; 56(4):254-260.^,4242. Sterling TR, Pope DS, Bishai WR, Harrington S, Gershon RR, Chaisson RE. Transmission of mycobacterium tuberculosis from a cadaver to an embalmer. N Engl J Med 2000; 342(4):246-248.

43. Sharma BR, Reader MD. Autopsy Room: A Potential Source of Infection at Work Place in Developing Countries. Am J Infect Dis 2005; 1(1):25-33.

44. Smith GS. Tuberculosis as a necropsy room hazard. J Clin Pathol 1953; 6(2):132-134.

45. McKenna MT, Hutton M, Cauthen G, Onarato IM. The association between occupation and tuberculosis. A population based survey. Am J Respir Crit Care Med 1996; 154(3Pt1):587-593.^-4646. Garg M, Aggarwal AD, Singh S, Kataria SP. Tuberculous Lesions at Autopsy. J Indian Acad Forensic Med 2011; 33(2):116-119.. Kantor et al.⁴⁷47. Kantor HS, Poblete R, Pusateri SL. Nosocomial transmission of tuberculosis from unsuspected disease. JAMA 1988; 84(5):833-837. report that the risk of acquiring the disease during the necropsy of people with tuberculosis is amplified by 17.8%. Wilkins et al.⁴⁸48. Wilkins D, Woolcock AJ, Cossart YE. Tuberculosis: medical students at risk. Med J Aust 1994; 160(7):395-397. confirmed this risk, reporting that 25% of students (negative Mantoux reactions) who participated in a necropsy of an immunocompromised patient in Australia developed tuberculosis. Garg et al.⁴⁶46. Garg M, Aggarwal AD, Singh S, Kataria SP. Tuberculous Lesions at Autopsy. J Indian Acad Forensic Med 2011; 33(2):116-119. demonstrated that 60% of the tuberculosis cases found during autopsy are unexpected. This data demonstrates the importance of adopting a precaution measures for the handling of bodies in disaster situations in countries where the tuberculosis incidence rate is high. This study detected tuberculosis as the second cause of deaths (18.459%).

The Koch bacillus can remain viable for long periods in corpses. Studies show the existence of infectious bacilli 24 to 48 hours after the embalming of an infected corpse¹³13. Weed I, Baggenstoss A. The isolation of pathogens from tissues of embalmed human bodies. Am J Clin Pathol 1951; 21(12):1114-1120.^,1919. Demiryürek D, Bayramoglu A, Ustacelebi S. Infective Agents in Fixed Human Cadavers: A Brief Review and Suggested Guidelines. Anat Rec (New Anat) 2002; 269(4):194-197.^,4242. Sterling TR, Pope DS, Bishai WR, Harrington S, Gershon RR, Chaisson RE. Transmission of mycobacterium tuberculosis from a cadaver to an embalmer. N Engl J Med 2000; 342(4):246-248..

M. tuberculosis transmission can occur through exposure to expelled fluids and/or air, through the respiratory tract during the putrefaction process or when residual air from the lungs is eliminated during corpse handling. Exposure may occur from gurgling at the nose and mouth of the cadaver due to fluid buildup in the chest cavity and putrefaction of tissues and organs. The risk is amplified when many bodies are stored in temporary locations, since the aerosol bacilli can remain viable for a long time⁵5. Gershon RR, Vlahov D, Escamilla-Cejudo JA, Badawi M, McDiarmid M, Karkashian C, Grimes M, Comstock GW. Tuberculosis risk in funeral home employees. J Occup Environ Med 1998; 40(5):497-503.^,1919. Demiryürek D, Bayramoglu A, Ustacelebi S. Infective Agents in Fixed Human Cadavers: A Brief Review and Suggested Guidelines. Anat Rec (New Anat) 2002; 269(4):194-197.^,2929. Conly JM, Johnston BL. Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005; 16(5):269-270.^,4545. McKenna MT, Hutton M, Cauthen G, Onarato IM. The association between occupation and tuberculosis. A population based survey. Am J Respir Crit Care Med 1996; 154(3Pt1):587-593.^,4949. Turner SB, Kunches LM, Gordon KF, Travers PH, Mueller NF. Occupational exposure to human immunodeficiency virus (HIV) and hepatitis B virus (HBV) among embalmer: a pilot seroprevalence study. Am J Public Health 1989; 79(10):1425-1426.. This risk can be reduced by placing a protective mask over the corpse’s air passages, when moving the body, and through adequate ventilation of the environment⁴4. World Health Organization. Management of dead bodies after disasters: a field manual for first responders. Washington: PAHO; 2006.

5. Gershon RR, Vlahov D, Escamilla-Cejudo JA, Badawi M, McDiarmid M, Karkashian C, Grimes M, Comstock GW. Tuberculosis risk in funeral home employees. J Occup Environ Med 1998; 40(5):497-503.^-66. Healing T, Hoffman P, Young S. The infection hazards of human cadavers. Commun Dis Rep CDR Rev 1995; 5(5):61-68.^,2929. Conly JM, Johnston BL. Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005; 16(5):269-270.^,3737. Mahajan A, Seema, Gandhi D. Human Cadavers-Review of Infectious Diseases. Int J Basic and App Med Sciences 2011; 1(1):66-69.^,5050. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities. Morb Mortal Wkly Rep 1994; 43(RR-13):1-112..

Infection from skin and mucous membranes occurs through direct contact with lesioned skin or contaminated objects. That mainly occur with methicillin-resistant Staphylococcus aureus and Group A Streptococcus pyogenes³⁷37. Mahajan A, Seema, Gandhi D. Human Cadavers-Review of Infectious Diseases. Int J Basic and App Med Sciences 2011; 1(1):66-69..

Methicillin-resistant Staphylococcus aureus (MRSA) is a nosocomial pathogen, which is disseminated among the population. Due to this prevalence, whether as a commensal or a pathogen, professionals who handle corpses are exposed a risk. Also Group A S. pyogenes represents a risk for the workers, because it can survive in corpses, and be transmitted by direct contact or as a result of inoculation.

Corpses usually eliminate fecal matter and may expose people who handle them to normal microorganisms present in the gastrointestinal tract²⁹29. Conly JM, Johnston BL. Natural disasters, corpses and the risk of infectious diseases. Can J Infect Dis Med Microbiol 2005; 16(5):269-270.. This exposure can occur through the fecal-oral via through direct contact or contact with contaminated objects or equipment, such as stretchers and vehicles used for transportation and storage. The most worrying biological agent in this case is Hepatitis A virus, while Shigella, Salmonella typhi, Helicobacter pylori and Cryptosporidium represent a lower risk¹²12. Morgan O. Infectious disease risks from dead bodies following natural disasters. Pan Am J Public Health 2004; 15(5):307-312.. Thus, the gastrointestinal microorganisms do not survive long in the environment and represent a low infection risk⁶6. Healing T, Hoffman P, Young S. The infection hazards of human cadavers. Commun Dis Rep CDR Rev 1995; 5(5):61-68..

Simple measures can reduce the infection risk associated with corpse handling, such as standard precautions for handling blood and body fluids and contact precautions. These practices include the use of gloves. The special gloves, as cut resistant or specific for chemicals, must be established during risk assessment. Avoid the manipulation of personal objects while wearing contaminated gloves. Protective clothing is recommended, like coveralls, made by polyethylene. Wearing closed shoes or boots is compulsory. Disposable filter masks (N95) must be used for respiratory protection from aerosolization risk. If there is a risk of splashes of chemicals, blood or any fluids, the use of protective goggles is recommended.

Upon arrival at the disaster area, the professionals must assess the ground, to observe the elevations, in order to anticipate the risk of an avalanche or a falling stone that could cause injury to the individuals who are working in the lower parts of the terrain. In these cases, protection for the head must be used.

All disposable protective equipment must be disposed in bags identified with the hazard symbol. Wash hands after handling corpses and before eating. All equipment, including clothes, stretchers and vehicles used for transportation, must be washed and decontaminated.

Transport bags body hinder the ventilation, increasing the decomposition rate, especially in hot climates⁶6. Healing T, Hoffman P, Young S. The infection hazards of human cadavers. Commun Dis Rep CDR Rev 1995; 5(5):61-68.^,1212. Morgan O. Infectious disease risks from dead bodies following natural disasters. Pan Am J Public Health 2004; 15(5):307-312.^,3737. Mahajan A, Seema, Gandhi D. Human Cadavers-Review of Infectious Diseases. Int J Basic and App Med Sciences 2011; 1(1):66-69.^,5151. Cutter M. Infection Control. In the bag? Nurs Times 1999; 95(2):55-56..

The professionals must be immunized against Hepatitis B. The vaccine leads to immunity in 90 to 95%¹⁹19. Demiryürek D, Bayramoglu A, Ustacelebi S. Infective Agents in Fixed Human Cadavers: A Brief Review and Suggested Guidelines. Anat Rec (New Anat) 2002; 269(4):194-197.^,3737. Mahajan A, Seema, Gandhi D. Human Cadavers-Review of Infectious Diseases. Int J Basic and App Med Sciences 2011; 1(1):66-69.. The BCG vaccine is recommended for protecting against tuberculosis, with a reactive or weak reactive tuberculin test and without immunosuppression⁵²52. Fritzsche FR, Ramach C, Soldini D, Caduff R, Tinguely M, Cassoly E, Moch H, Stewart A. Occupational health risks of pathologists – results from a nationwide online questionnaire in Switzerland. BMC Public Health 2012; 12:1054-1066.. In addition, a three-dose of the Td vaccine is recommended in order to reach an adequate level of protection against tetanus and diphtheria in people who were not vaccinated in the past. Individuals who were vaccinated in childhood and who received their last dose for over 10 years, require only one dose of the vaccine⁵³53. Brasil. Ministério da Saúde (MS). Manual dos Centros de Referência para Imunobiológicos Especiais. Brasília: MS; 2006..

Conclusion

Natural disasters and outbreaks of infectious diseases represent global challenges for reaching the Millenium Development Goals.

Natural disasters have been occurring continually in the world, sometimes leading to a displacement of people, which aggravates the factors that favor transmission of diseases. It is importante for policy makers, health authorities and professionals involved in emergency care, to understand the mechanisms involved in the dissemination of diseases, to realize that corpses in disaster situations are not a source of epidemics, and that disease outbreaks may be a secondary result of the increased local risk factors for disease occurrence. The same happens with victims of warfare. In both cases, it is probable that the survivors are the source of disease outbreaks. The rapid implementation of control measures, early warning and surveillance, must be a priority, especially in the absence of epidemiological surveillance data from pre-disaster. It is essential, in these areas, to intensify disease surveillance mechanisms and compulsory notification in the health units where victims are cared for, since exotic pathogens can be imported or can emerge and re-emerge in the region affected by the disaster.

Nonetheless, the professionals involved in emergency care can be exposed to chronic risks, such as blood-transmitted viruses, gastrointestinal infections and tuberculosis. The risk to this group can be estimated based on the identification of deaths, existing epidemics and the prevalence of endemic diseases in the local population and the probability of exposure and transmission.

In natural environments, there is a variety of biological risk agents, which can be occasional infection sources, such as: infection via ingestion of pathogens in water or contaminated food (gastroenteritis, cholera); infection via inhalation (histoplasmosis, cryptococcosis and tuberculosis); percutaneous infection by inoculation (tetanus, deep micosis), penetration (leptospirosis, schistosomiasis) or vector bites (arboviruses, malaria, trypanosomiasis and leishmaniasis).

Geographical location and local environmental conditions, influenced by light, humidity, altitude, heat, fauna, vegetation, pollution and degree of human interference, among others, also modify the risk, increasing or reducing agent susceptibility according to the interaction of the various epidemiological factors. Too the affected population’s living conditions must be evaluated, with special attention to the availability of potable water and sanitation, as well as the age distribution, nutritional state and vaccine coverage of the people affected, and how much access they have to health care. When monitoring the incidence of infectious diseases and documenting their impact in these conditions, it is possible to better quantify the outbreak risk that follows natural catastrophes.

Since the HIV epidemic, the emergence of multi-drug resistant bacterial strains (such as Staphylococcus aureus resistant to meticillin and Enterococcus sp. resistant to vancomycin), the reemergence of tuberculosis in the global population, the dispersion of Extensively Drug-Resistant Tuberculosis (XDR-TB) and the higher risk of acquisition of blood-transmissible biological agents (HIV and viral B and C Hepatitis, for example), disasters require the professionals involved to be trained in implementing biosafety measures in terms of procedures, identification and protective equipment use, in order to prevent accidental exposure.

Every country must prepare itself by implementing a response plan to disasters; training health care professionals and those involved in emergency care in the identification, diagnosis and treatment of diseases and in the establishment of the necessary protection and containment measures. In these situations, simple hygiene and sanitation measures, such as the action of washing hands, and the supply of potable water, shelters and adequate sanitary facilities are important for the prevention and control of infectious diseases. Thus, when preparing for the inevitable, medical response staff and the professionals involved in emergency care will be better able to alleviate the suffering which occurs after natural disasters.

Acknowledgements

This work was performed with support from the CNPq – Brazil (National Council for Scientific and Technological Development) through the project Post-doctorate Abroad.

References

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