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Infective agents in fixed human cadavers: A brief

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THE ANATOMICAL RECORD (NEW ANAT.) 269:194 197, 2002

ARTICLE

Infective Agents in Fixed Human Cadavers:

A Brief Review and Suggested Guidelines
DENIZ DEMIRYUREK,* ALP BAYRAMOGLU, AND SEMSETTIN USTACELEBI

Cadavers remain a principal teaching tool for anatomists and medical educators teaching gross anatomy. Infectious
pathogens in cadavers that present particular risks include Mycobacterium tuberculosis, hepatitis B and C, the AIDS
virus HIV, and prions that cause transmissible spongiform encephalopathies such as Creutzfeldt-Jakob disease (CJD)
and Gerstmann-Straussler-Scheinker syndrome (GSS). It is often claimed that fixatives are effective in inactivation of
these agents. Unfortunately cadavers, even though they are fixed, may still pose infection hazards to those who
handle them. Specific safety precautions are necessary to avoid accidental disease transmission from cadavers
before and during dissection and to decontaminate the local environment afterward. In this brief review, we describe
the infectious pathogens that can be detected in cadavers and suggest safety guidelines for the protection of all who
handle cadavers against infectious hazards. Anat Rec (New Anat) 269:194 197, 2002. 2002 Wiley-Liss, Inc.

KEY WORDS: cadaver dissection; education; medical curriculum; gross anatomy; infection; mycobacterium tuberculosis;
hepatitis; AIDS; HIV; prion; spongiform encephalopathy; Creutzfeldt-Jakob Disease; CJD

INTRODUCTION encephalopathies (Weed and Bag- INFECTIOUS DISEASES AND

Like all other occupations, being a
member of an anatomy department
has its own risks. The potential infec-
tion hazard of human cadavers is one
of them. Cadavers are the main study-
ing materials of anatomists (Aziz et
al., 2002) but may pose infection risks
to people who handle them during
embalming procedures or dissections.
Infectious pathogens in the cadavers
that present particular risks include
Mycobacterium tuberculosis, hepatitis
B and C viruses, HIV, and prions
that cause transmissible spongiform
genstoss, 1951; Brown et al., 1986;
Roth et al., 1992; De Craemer, 1994;
Healing et al., 1995; Kappel et al.,
1996; Catteneo et al., 1999). The em-
balming fluid used in anatomy depart-
ments contains fixatives, disinfec-
tants, glycerol, salts, and water. There
Like all other
occupations, being a
member of an anatomy
department has its own
THEIR AGENTS
Tuberculosis
Tuberculosis is a slowly progressive,
chronic infection usually of the
lungs, but many other organs can
become affected. The infective
agent, M. tuberculosis, is an acid-
fast, slender, beaded bacillus and
can be cultured on Lowenstein-
Jensen medium as rough, dry, and
yellow colonies (Sleigh and Tim-
burry, 1998). Tuberculosis was one
of the biggest killers among the in-
fectious diseases in the past. The an-

Drs. Demiryurek and Bayramoglu are in

the Department of Anatomy, Hacettepe
University Faculty of Medicine, Ankara,
Turkey. They are interested in the occu-
pational diseases of anatomists and
those who work with cadavers. Dr. Us-
tacelebi, of the Department of Clinical
Microbiology at Hacettepe University
Faculty of Medicine, has the special
study topic of prion diseases.
*Correspondence to: Deniz Demiryurek,
M.D., Ph.D., Hacettepe University Fac-
ulty of Medicine, Department of Anat-
omy, 06100, Ankara, Turkey. Fax: !90-
312-310-71-69; E-mail: ddeniz@tr.net or
mdeniz@hacettepe.edu.tr
DOI 10.1002/ar.10143
Published online in Wiley InterScience
(www.interscience.wiley.com).
risks. The potential
infection hazard of
human cadavers is one
of them.
are inadequate data in the literature
about the disinfectant efficiencies of
fluids used for embalming. The pur-
pose of this review is to draw atten-
tion to the infective agents that can be
detected in fixed human cadavers and
to suggest safety guidelines for the
protection of all who handle cadavers.
nual number of tuberculosis cases
continues to increase due to its
emergence in HIV infections. The
risk of acquiring tuberculosis varies
according to occupation, and anat-
omy department workers are at par-
ticularly risk of contracting tubercu-
losis carried by cadavers (Smith,
1953; Kappel et al., 1996; Sterling et
al., 2000). Of particular concern is
the growing number of multiple-
drugresistant strains that have
evolved in recent years.
Transmission of M. tuberculosis is
thought to occur primarily by expo-
sure to aerosolized infectious bacilli.

2002 Wiley-Liss, Inc.

ARTICLE
Infected particles and splashes con-
taining tuberculous material can be
acquired during respiration (Sloan,
1942; Harrington and Shannon,
1976). The increased risk of tubercu-
losis among employees who handle
cadavers was demonstrated through
tuberculin skin testing (McKenna et
al., 1996; Gershon et al., 1998).
It is generally thought that the risk
of transmission is decreased by fixa-
tion, and some authors agree with a
commonly held belief that formalin
is tuberculocidal (Weed and Bag-
genstoss, 1951; Johnson et al., 1953;
Smith, 1953). Although it was previ-
ously reported that tubercle bacilli
from cadavers were not infectious
(Meade and Steenken, 1949) and trials
for culturing M. tuberculosis from
10% buffered formalin-fixed pulmo-
nary autopsy tissues have been unsuc-
cessful (Kappel et al., 1996), it has
been shown that bacilli remain viable
and, therefore, infectious for at least
24 to 48 h after an infected cadaver
has been embalmed (Weed and Bag-
genstoss, 1951). There is also a case
report describing the transmission of
M. tuberculosis from a cadaver to an
embalmer during the embalming pro-
cess, with the subsequent develop-
ment of active tuberculosis (Sterling
et al., 2000). Based on the contradic-
tory published data, the disinfection
properties of fixatives for tuberculosis
infected tissue remain unclear.
Viral Hepatitis
Hepatitis can be seen in many viral
diseases such as yellow fever, cyto-
megalovirus and Epstein-Barr infec-
tion, and congenital rubella. However,
viral hepatitis is caused by infections
by viruses that primarily target the
liver. There are six types of hepatitis
viruses: A, B, C, D, E, and F types.
Hepatitis A is transmitted by the oral
route by means of food contaminated
with fecal matter. Hepatitis B is ex-
tremely infectious. It might be trans-
mitted by blood or blood products,
sexual transmission, and skin pene-
tration through contact with infected
material. Hepatitis C is transmitted by
the same routes as hepatitis B but is
probably less infectious (Timburry,
1997).
Most of the studies made on cadav-
eric tissue donors revealed that the
THE ANATOMICAL RECORD (NEW ANAT.) 195
availability of cadaveric tissue as a
transplantation material is often lim-
ited by pathogenic organisms which it
may contain. Specific serologic mark-
ers of hepatitis B and C viruses can be
detected in cadaveric tissue banks
(hepatitis B surface ag 18.1% and hep-
atitis C ab 14.3%) (Barnett et al.,
2001) and in postmortem blood tests
for body donation programs (Roth et
al., 1992; Watkins et al., 1998). The
prevalence of HIV and hepatitis C
markers has been studied among a
cadaver population, and the cases rep-
resented a high prevalence of sero-
logic markers for HIV and hepatitis C
virus infection (Catteneo et al., 1999).
It has been reported that organ trans-
plantation from cadavers can trans-
mit hepatitis (Lutwick et al., 1983).
Workers in morbid anatomy also face
risk of contamination (Smith,
1953),which raises serious questions
about the infective hazards of cadav-
Can an individual who
died of AIDS still be
infectious at the time of
arrival in the anatomy
department as a
cadaver? Unfortunately,
the answer is YES.
ers and the effectiveness of fixatives
against hepatitis viruses.
AIDS
HIV, the cause of AIDS, is one of the
most intensively investigated viruses.
The cytopathic effect of HIV on T4
helper lymphocytes causes the failure
of the immune system and results in
AIDS. Human immunodeficiency vi-
rus is an RNA virus with typical retro-
virus structure, and it is transmitted
by similar routes as hepatitis B (Tim-
burry, 1997).
Can an individual who died of AIDS
still be infectious at the time of arrival
in the anatomy department as a ca-
daver? Unfortunately, the answer is
YES. Infectious HIV has been re-
ported in pleural fluid, pericardial
fluid, and blood of such deceased pa-
tients after storage at 2C for up to
16.5 days after death (Douceron et al.,
1993). Viable HIV was also isolated
from bone fragments, spleen, brain,
bone marrow, and lymph nodes from
a patient with AIDS at autopsy 6 days
postmortem (Nyberg et al., 1990). Al-
though in suspension tests, 25% etha-
nol and 0.5% formaldehyde were
shown to be effective against HIV
(Sattar and Springthorpe, 1991), it is
not clear whether these concentra-
tions are also effective in cadavers (De
Craemer, 1994). On the other hand,
cadavers infected with HIV are often
infected with opportunistic infec-
tions, such as tuberculosis, which
may be more infectious then HIV in-
fection itself (Healing et al., 1995).
Prion Diseases and
Transmissible Spongiform
Encephalopathies
The transmissible spongiform encepha-
lopathies (TSEs) are degenerative dis-
eases of the central nervous system.
Two of these found in humans are
Creutzfeldt-Jakob disease (CJD) and
Gerstmann-Straussler-Scheinker (GSS)
syndrome. GSS is distinct from CJD;
GSS is thought to be familial but is
known to occur sporadically as well.
CJD is characterized by loss of motor
control, dementia, paralysis, and death
secondary to pneumonia.
The infectious agent that causes
CJD has been called a prion and can
be defined as small proteinaceous in-
fectious particles resistant to inactiva-
tion by procedures that modify nu-
cleic acids. It might be transmitted by
diet or after medical procedures such
as surgery, cadaver pituitary-derived
growth hormone injections, and ca-
daveric dural grafts or cornea trans-
plants (Billette de Villemeur and
Pradel, 1994; Budka et al., 1995).
Prion is highly resistant to conven-
tional methods of sterilization and
disinfection (Brown et al., 1982). It
has been shown that a related agent
that causes scrapie survived inter-
ment for 3 years with infectivity
(Brown and Gajdusek, 1991). The CJD
agent has been shown to survive well
in formalinized tissue, and it has been
experimentally demonstrated that
transmission of prion from formalin-
ized brain tissue to mice is possible
(Brown et al., 1986). Also, the CJD
196 THE ANATOMICAL RECORD (NEW ANAT.)
causative agent has been shown to
stay infective in ash at 360C after
formaldehyde fixation (Brown et al.,
1990). The evidence of risk to those
who handle infected tissue has been
supported by case reports of this dis-
ease in morbid anatomy workers
(Miller, 1988).
PROCEDURES AND
PRECAUTIONS
The information given above indi-
cates that a cadaver might be still in-
fectious at the time of arrival in an
anatomy department for subsequent
educational purposes. Therefore, spe-
cific safety precautions are mandatory
from the moment of the cadavers ar-
rival at the facility.
Preparation for Dissection
The corpse must have a detailed file,
indicating the reason of death and
containing previous hospital records
if possible. Working on cases known
to be infectious with M. tuberculosis,
hepatitis B and C, HIV, and prions
should be avoided. Every cadaver
should be regarded as an infectious
material. During the transportation
process, disposable body bags must
be used. The risk to department per-
sonnel of respiratory tract pathogens
from the deceased is probably remote,
even from the single exhalation of air
that occurs when the body is first
moved. Covering the face of the body
with a cloth would be a simple precau-
tion (Healing et al., 1995).
Proper protective clothing must be
used by the department personnel
for avoiding accidental transmission
(CDC, 1988). Single-use latex exami-
nation gloves must be worn whenever
handling bodies; they should be used
once only and then discarded. Safety
gloves (e.g., Teflon-made from spec-
tra, or metallic gloves) should be worn
over examination gloves to protect
from longer term exposure to chemi-
cal hazards and accidental penetrat-
ing wounds. Filter masks must be
used for respiratory protection from
specific hazards, such as lead dust,
fungal spores, and aerosols. Face vi-
sors should be worn for protection
against hazardous splashes to eyes,
nose, and mouth. Disposable aprons
or gowns must be used for protection
against splashes to the body. Contam-
ination of the dissection table should
be avoided by a nonpermeable, dis-
posable plastic sheet or similar mate-
rial (Budka et al., 1995; Healing et al.,
1995).
Embalming Chemicals
Although embalming is thought to re-
duce the infectious risks, there is in-
adequate information about the disin-
fectant properties of fluids commonly
used to embalm cadavers. The em-
balming fluid used in anatomy depart-
ments contains fixatives, disinfec-
tants, surfactants, buffers, glycerol,
salts, and water. The most frequently
used fixatives and disinfectants are
formalin, ethanol, and phenol. For-
malin, a 37% aqueous solution of
formaldehyde gas, inactivates infec-
tious agents by forming covalent
cross-links with several organic func-
tional groups on proteins. Although
formaldehyde is known to be a high-
level germicide that has the capacity
to kill all microbes and viruses, it is
ineffective against the CJD agent as
mentioned above.
Every cadaver should
be regarded as an
infectious material.
Ethanol is one of the most com-
monly used alcohols to control micro-
bial growth. Its mechanism of action
involves protein denaturation and
lipid dissolution. Ethanol can be used
alone in concentrations of 60 to 95%
or in combination with other antimi-
crobial agents in lower concentra-
tions. It is known to be effective
against bacteria and fungi but not en-
dospores, nonenveloped viruses, or
prions.
Phenol and its derivative phenolics
exert antimicrobial activity by inacti-
vating essential cell enzymes and in-
juring lipid-containing plasma mem-
branes, which results in leakage of
cellular contents. At concentrations
above 1%, phenol and phenolics have
an antibacterial effect. They have a
broad spectrum of activity against
bacteria, viruses, and fungi, but they
are ineffective against prions.
ARTICLE
In suspension tests, these fixatives
and disinfectants were shown to be
effective against most of the bacteria
and viruses (Rutala, 1996). However,
it is not clear whether they are also
effective in cadavers, for several rea-
sons. First, in suspension tests, the
cell-free infectious agent is tested,
whereas in humans, some infective
agents (such as HIV) can localize
within cells. Second, the concentra-
tion of the embalming fluid compo-
nents decreases as they diffuse
throughout the human body. Third,
several classes of products, includ-
ing formalin, alcohols, and phenolic
agents, are partially inactivated by the
presence of protein. This sensitivity to
organic load suggests that the effi-
ciency of the disinfectants will be
much lower in cadavers than in vitro
tests (De Craemer, 1994). Fourth, al-
though a certain fixative at certain lev-
els may be cidal to a single agent or
even a group or class of infectious
agents, other agents that co-exist may
survive as mentioned above; thus,
complete disinfection may not be ac-
complished.
Postdissection Decontamination
After the dissection is completed, tis-
sue remnants, cutting debris, the
sheet covering the table, and all the
disposable material should be dis-
carded within a plastic container as
infectious hospital waste. All instru-
ments that came into contact with po-
tentially infectious material must be
decontaminated. Although the con-
ventional methods of sterilization and
disinfection are effective for most of
the infective agents, they do not de-
contaminate prions (Miller, 1988).
Specific measures must be used for
prions, and these measures will also
be adequate for other infective agents.
One of the most effective procedures
is steam autoclaving (instruments,
safety gloves, etc.) at 134C with 30 lbs
psi for 60 min (Committee on Health
Care Issues, 1986). Chemical decon-
tamination with 2 N NaOH for 1 h or
1 N NaOH for 2 h is an alternative for
nonautoclavable materials and sur-
faces. It is not recommended to use
NaOH for aluminium material. Boil-
ing of instruments in 3% sodium do-
decyl sulfate (SDS) at least 3 min is
another option. Autoclaving can be
 ARTICLE
used either alone or in combination
with using SDS or NaOH. Alterna-
tively, 5% NaOCl (at least 20,000 ppm
free chloride) can be used for 2 h, but
this chemical is very irritating and
corrosive to steel (Tateishi et al.,
1991).
The environment should be cleaned
with a phenolic disinfectant (contain-
ing 35% active ingredient) daily. This
method is preferred to hypochlorite for
several reasons: hypochlorite is a corro-
sive chemical and may damage surfaces
or instruments; cleaning large areas
with hypochlorite may liberate unac-
ceptable amounts of chlorine; and
formaldehyde reacts with hypochlorite
to produce a potent carcinogen, bis-
chloromethyl ether (Gamble, 1977).
CONCLUSION
The potential infection hazard from
human cadavers is one of the risks of
being a member of an anatomy de-
partment. Special care must be taken
to reduce risks to a minimum. Safe
working conditions for handling ca-
davers can be provided through
proper education, use of protective
clothing, and practice of hygienic
measures. Although following the rec-
ommendations mentioned can reduce
the risk of infectious hazards of ca-
davers, vaccination of all who handle
cadavers against hepatitis B and M.
tuberculosis (Sterling et al., 1999) is
another important precaution that
should not be missed. Finally, dissec-
tion laboratory directors must stay up
to date on the most recent literature in
the field to help ensure the safety of all
educators, researchers, and students
under their charge.
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