MDR Tuberculosis, Hepatitis B and a Student on Placement

Decision: embalm - but with a written risk assessment and a modified sequence.

Reasoning:

• Tuberculosis is not, by itself, a bar to embalming. The post-mortem risk is not the coughing patient of the ward; it is the aerosol generated by your procedures. Arterial injection itself is low risk. The high-risk moments are cavity aspiration, any suction that vents into the room, and opening the thorax.
• Formaldehyde at embalming strength is mycobactericidal, so fixation of the tissue reduces viable organisms - which is an argument for injecting before aspirating.
• Sequence to use: arterial injection first; then cavity aspiration using a closed system with suction running continuously, the vent kept away from your face and below the level of your breathing zone, and the trocar not driven repeatedly through lung tissue. Aspirate slowly so the cavity does not decompress in a sudden burst.
• Because MDR-TB raises the consequence of any infection, escalate PPE for the aspiration step: fit-tested FFP3 respirator, eye protection, fluid-resistant gown. Standard surgical mask is inadequate for an aerosol-generating step.
• Waste fluid and sharps go into the infectious-clinical-waste stream, labelled, not down the drain.

Decision: neither student takes part in invasive or aerosol-generating steps as things stand; the pregnant student is excluded from the aspiration step entirely.

Reasoning:

• Hepatitis B is a bloodborne risk, and the virus survives in dried blood. The unvaccinated student has no documented immunity, so any splash or needlestick is a real exposure. Non-immune staff should not perform invasive procedures; arrange vaccination and post-vaccination anti-HBs testing first, and in the meantime limit her to non-invasive tasks outside the room.
• Pregnancy does not make tuberculosis uniquely hazardous to the fetus in this setting, but the precautionary principle applies to aerosol exposure, and it is worth remembering that the classic pregnancy-relevant mortuary agents are parvovirus B19 and cytomegalovirus - a reason to be careful rather than dismissive. Exclude her from the aerosol-generating step and from handling blood-contaminated materials where avoidable.
• Note that the two risks are different in kind: hepatitis B is a vaccine-preventable bloodborne hazard, tuberculosis is an airborne hazard. A single "extra PPE" answer misses the point; each student is restricted for a different reason, and both decisions are recorded in the risk assessment.
• The pregnant student should be told the reasoning, not simply moved aside - she is entitled to understand the assessment made about her.

Decision: reassure, do not disclose the diagnoses, and answer the actual question asked.

Reasoning:

• Confidentiality continues after death. Neither tuberculosis nor hepatitis B is disclosed to the family as an explanation for your precautions; doing so would breach confidence and could stigmatise the deceased.
• Answer the practical question honestly. An open casket after embalming is safe for the family. Any infection risk to them arose during his life and from close contact then, not from a fixed, embalmed body.
• On contact: touching the hand or the face at a viewing is normal and can be permitted; discourage open-mouthed kissing or any contact with secretions, and say so in neutral, caring terms - "we usually suggest a kiss on the forehead or holding his hand" is better than a list of prohibitions.
• Offer something concrete: arrange the viewing at a time when a member of staff is present, and give the family the chance to ask questions then. The purpose of the conversation is a family who feel welcome rather than managed.