Mental Health Status of Canadian Funeral Service Workers at the Beginning of the COVID-19 Pandemic.

OBJECTIVE: To describe the mental health situation and job stress levels of Funeral Service Workers (FSW) during the first months of the pandemic. METHODS: We conducted a cross-sectional study in Canada between May and July 2020. Funeral service professional organizations were asked to spread a questionnaire to their members including job description, assessment of anxiety (GAD-7), depression (PHQ-8), and job stress (effort-reward imbalance questionnaire). RESULTS: Fifty-eight FSW completed a questionnaire, 32% reported anxiety symptoms (GAD-7 > 10), 29% reported depressive symptoms (PHQ-8 > 10), 31% reported job stress. Women were more likely to report overcommitment (66.7% vs. 31.8%, P = 0.015). CONCLUSIONS: Levels of anxiety and depression identified in Canadian FSW were higher than those identified in other occupational groups during the first few months of the pandemic.

Evaluation of an HIV-Related Mortuary Surveillance System - Nairobi, Kenya, Two Sites, 2015.

PROBLEM/CONDITION: Use of human immunodeficiency virus (HIV)-mortality surveillance data can help public health officials monitor, evaluate, and improve HIV treatment programs. Many high-income countries have high-coverage civil registration and vital statistics (CRVS) systems linked to case-based HIV surveillance on which to base HIV mortality estimates. However, in the absence of comprehensive CRVS systems in low- and medium-income countries, such as Kenya, mortuary surveillance can be used to understand the occurrence of HIV infection among cadavers. In 2015, a pilot HIV-related mortuary surveillance system was implemented in the two largest mortuaries in Nairobi, Kenya. CDC conducted an evaluation to assess performance attributes and identify strengths and weaknesses of the surveillance system pilot. PERIOD COVERED: Data collection: January 29-March 3, 2015; evaluation: November 2015. DESCRIPTION OF THE SYSTEM: The surveillance system objectives were to determine HIV positivity among cadavers at two mortuary sites in Nairobi, Kenya, and to determine annual cause-specific and HIV-specific mortality rates among the cadavers. Cadavers of persons aged ≥15 years at death admitted to either mortuary during a 33-day period were included. Demographic information and place and time of death were entered into a surveillance register. Cardiac blood was collected using transthoracic aspiration, and blood specimens were tested for HIV in a central laboratory. Causes of death were abstracted from mortuary and hospital records. Of the 807 cadavers brought to the mortuaries, 610 (75.6%) had an HIV test result available. The overall unadjusted HIV-positivity rate was 19.5% (119/610), which differed significantly by sex (14.6% among men versus 29.5% among women). EVALUATION: The evaluation was conducted using CDC guidelines for evaluating public health surveillance systems. The attributes of simplicity, flexibility, data quality (completeness and validity), acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability were examined. The evaluation steps included review of the surveillance system documents, in-depth interviews with 20 key informants (surveillance system staff, including mortuary and laboratory staff, and stakeholders involved in funding or implementation), and review of the surveillance database. RESULTS AND INTERPRETATION: Implementation of the pilot mortuary surveillance system was complex because of extensive paperwork and the need to collect and process specimens outside of business hours. However, the flexibility of the system accommodated multiple changes during implementation, including changes in specimen collection techniques and data collection tools. Acceptability was initially low among the mortuary staff but increased after concerns regarding workload were resolved. Timeliness of specimen collection could not be measured because time of death was rarely documented. Completeness of data available from the system was generally high except for cause of death (46.5%). Although the two largest mortuaries in Nairobi were included, the surveillance system might not be representative of the Nairobi population. One of the mortuaries was affiliated with the national referral hospital and included cadavers of admitted patients, some deaths might have occurred outside Nairobi, and data were collected for only 1 month. PUBLIC HEALTH ACTIONS: Mortuary surveillance can provide data on HIV positivity among cadavers and HIV-related mortality, which are not available from other sources in most sub-Saharan African countries. Availability of these mortality data will help describe a country's progress toward achieving epidemic control and achieving Joint United Nations Programme on HIV/AIDS 95-95-95 targets. To understand HIV mortality in high-prevalence regions, the mortuary surveillance system is being replicated in Western Kenya. Although a low-cost system, its sustainability depends on external funding because mortuary surveillance is not yet incorporated into the national AIDS strategic framework in Kenya.

Mortuary based injury surveillance for low-mid income countries: process evaluation of pilot studies.

OBJECTIVE: Globally, injury is the fourth major cause of death and the third leading contributor to Disability Adjusted Life Years lost due to health conditions, with the greatest burden borne by low-middle income countries (LMICs) where injury data is scarce. In the absence of effective vital registration systems, mortuaries have been shown to provide an alternative source of cause of death information for practitioners and policy makers to establish strategic injury prevention policies and programs. This evaluation sought to assess the feasibility of implementing a standardised fatal injury data collection process to systematically collect relevant fatal injury data from mortuaries. The process evaluation is described. METHODS: A manual including a one page data collection form, coding guide, data dictionary, data entry and analysis program was developed through World Health Organization and Monash University Australia collaboration, with technical advice from an International Advisory Group. The data collection component was piloted in multiple mortuaries, in five LMICs (Egypt, India, Sri-Lanka, Tanzania and Zambia). Process evaluation was based on a questionnaire completed by each country's Principal Investigator. RESULTS: Questionnaires were completed for data collections in urban and rural mortuaries between September 2010 and February 2011. Of the 1795 reported fatal injury cases registered in the participating mortuaries, road traffic injury accounted for the highest proportion of cases, ranging from 22% to 87%. Other causes included burns, poisoning, drowning and falls. Positive system attributes were feasibility, acceptability, usefulness, timeliness, and simplicity and data field completeness. Some limitations included short duration of the pilot studies, limited injury data collector training and apparent underreporting of cases to the medico-legal system or mortuaries. CONCLUSION: The mortuary has been shown to be a potential data source for identifying injury deaths and their circumstances and monitoring injury trends and risk factors in LMICs. However, further piloting is needed, including in rural areas and training of forensic pathologists and data-recorders to overcome some of the difficulties experienced in the pilot countries. The key to attracting ongoing funding and support from governments and donors in LMICs for fatal injury surveillance lies in further demonstrating the usefulness of collected data.

Predictors of depression among a sample of South African mortuary workers.

Mortuary workers are at high risk of developing depression and other psychiatric disorders owing to the nature of their work and exposure to deceased victims of violent deaths. Few studies have investigated mental health among mortuary workers in low- and middle-income countries. Participants (N = 45) were recruited from mortuaries in South Africa and completed a battery of questionnaires measuring depression, physical health, perceived stress, fear of blood/injury/mutilation, and resilience. Participants with self-reported depression and posttraumatic stress disorder (PTSD) comprised 13.3% and 4.4% of the sample, respectively. Inexperienced mortuary workers had a higher prevalence rate of depression (16.7%) compared with experienced workers (9.5%). Prevalence of PTSD did not differ significantly between inexperienced (4.2%) and experienced (4.8%) workers. Physical health, perceived stress, fear of blood/injury/mutilation, and resilience were significant predictors of depression in the combined group (experienced and inexperienced). However, perceived stress was the only significant predictor of depression, in multiple regression, in the combined group. Inexperienced workers had significantly higher levels of blood/injury/mutation fear and depression. Mortuary workers seem to be at increased risk of depression, especially inexperienced workers. Perceived poor health, lower levels of resilience, and blood/injury/mutilation fears may lead to increased perceived stress among mortuary workers, which may, in turn, lead to depression. Interventions focused on promoting mental health may be beneficial to all mortuary workers, and preparatory training related to mental health may be beneficial to inexperienced mortuary workers before occupational uptake.

A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial.

This study explored the challenges in establishing a mortuary-based injury surveillance system in a resource-constrained setting of Ibadan, Nigeria. To quantify and detail fatal injuries, in September 2010 to February 2011, a prospective data collection utilised the World Health Organization-Monash draft surveillance system. Findings were compared with other low- and middle-income settings, and surveillance system attributes were assessed. The leading injury mechanism among all age groups was transport related, with 45.6% being vulnerable road users, consistent with comparable settings. Fire-related injury was the second unintentional cause in the Ibadan pilot, unlike Global Burden of Disease estimates for Nigeria, Mauritius and Mexico, where drowning was the second cause. Positive system attributes included timeliness, data field completeness, specificity, flexibility and sensitivity. Despite apparent under-reporting of eligible deaths and questionable representativeness, this study illustrates potential for mortuary data to inform injury prevention policies and programmes in resource-constrained settings.

Are we all equal at death?: death competence in municipal cemetery management.

Managers of local government cemeteries should balance social and cultural expectations with fiscal responsibility and when they do so they demonstrate death competence in cemetery management. This study reviews the cultural and social equity aspects of the consumption of cemetery services and develops tools to take into account social equity and cultural concerns for public sector cemetery managers. Cemetery demand and pricing models are developed and applied to the case of Austin, Texas. These models enhance the estimation of demand by taking into account cultural factors and contextualize pricing in terms of social equity concerns.

Fatal road traffic injuries in Ibadan, using the mortuary as a data source.

BACKGROUND: Road Traffic Injury (RTI) in Africa represents 14% of global RTI deaths. Lack of timely, reliable data undermines road safety interventions. Available fatality data are aggregated, limited in detail or scarce in surveys. This is the first fatal RTI surveillance study in Nigeria. OBJECTIVE: To pilot a systematic mortuary-based data collection in Ibadan, determine the nature and circumstances of fatal RTI and assess data quality against existing data sources. METHODS: Using a draft data collection system developed jointly by WHO and Monash University, the detailed information was prospectively collected on RTI University College Hospital mortuary admissions in Ibadan September 2010 to February 2011. Demographics, road user type, counterpart vehicle, intent, manner and medical cause of death were recorded. RESULTS: Mortuary admissions included 80 fatal RTI cases: 81.3% males. By road user category, 28 (35.0%) were pedestrians; 28 (35.0%) motorised 2-wheeler users; 18.8% car occupants; and 11.3% bus occupants. In 70% of cases, medical cause of death was head injury, including 25 of 28 motorised 2-wheeler users (89.3%). Estimates from this study indicate apparent increased mortuary capture of fatal RTI compared with police data. CONCLUSIONS: This study demonstrates the feasibility of collecting detailed, timely RTI fatality data through mortuary-based surveillance in Ibadan. While not all RTI deaths are reported to any authority in Ibadan, this large case series complements existing data sources and suggests that pedestrians and motorised 2-wheeler users die most often in road traffic crashes. Frequent head injuries among motorised 2-wheeler users strongly support the need for helmet wearing interventions.

Exposure to blood among mortuary workers in teaching hospitals in south-west Nigeria.

BACKGROUND: Mortuary workers like other health workers are exposed to blood borne pathogens at work. A baseline assessment is important to plan for programmes to safeguard the health of workers. The aim of this study is to determine exposure rates to blood among mortuary workers in teaching hospitals in South West Nigeria. METHODS: A descriptive cross sectional study was carried out between March and May 2008. All mortuary workers working in six (6) teaching hospitals, 80 in total were included in the study. Data was collected with the aid of a 15- item self administered questionnaire. Data was analysed with the aid of EPI-INFO 2002. Statistical associations were explored using odds ratio and confidence intervals. RESULTS: A total of 76 respondents completed questionnaire giving a response rate of 95%; 3 males and 1 female declined to participate, the mean age of respondents was 38.2 years, 48(72.6%), 53(85.5%) and 50(73.5%) of the workers had been exposed to blood through cuts, blood splash and needle stick injury. Duration at work was significantly associated with blood splash. Workers who had worked 5 years and above were 0.10 times (95% confidence interval 0.00-.0.78) as likely to experience blood splash compared to those who had worked under 5 years. Only 5(10.4%) of workers with needle stick injury had completed three doses of Hepatitis B vaccine. The specific confirmation by antibody titre was however not done in this study. CONCLUSION: Exposure to blood was very common with blood splash emerging as the most common route of exposure. There is a need for vaccination of all mortuary workers with three doses of Hepatitis B Vaccine to protect their health. In addition, education of workers on risks and institution of standard operating procedure are crucial to safeguard the health of mortuary workers.

The mortuary as a source of injury data: progress towards a mortuary data guideline for fatal injury surveillance.

To help bridge the obstacle of inadequate injury fatality data in low and medium income countries (LMICs) a simple cost effective system for mortuary surveillance of fatal injuries is being developed in consultation with the WHO. This will inform, direct and monitor injury prevention (IP) interventions and policies in LMICs. This article uses CDC's 'attributes of a successful surveillance system' to describe the process, the barriers and solutions in development of this mortuary data guideline. The consultative process utilised generated feedback from key stakeholders including forensic pathologists, Ministry of Health officials and injury prevention experts. An International Advisory Group was also convened to guide the guideline development. These assisted the adjustment of the proposed guideline to maximise flexibility, acceptability and stability; whilst minimising resource implications. Representativeness and the securing of government support perhaps remain the most significant challenges. Consultation with the advisory group and the wider stakeholders has been effective in developing a widely acceptable, user-friendly, low resource data form to gather useful data. Further strategies to overcome barriers need to be developed over the course of the pilot study and this should be done in consultation with the advisory group and stakeholders.

"No one has ever asked for it back!" A survey assessing the fate of reusable external fixation equipment in mortuaries.

Technicians from one hundred and eighteen Human Tissue Authority (HTA) approved mortuaries licensed to perform post-mortems in England completed a telephone interview. All were questioned on whether they had contact with reusable external fixators, who was responsible for the removal, the number removed annually, and the destination of the fixator post-removal. Opinion was sought on how the return of the equipment could be better facilitated. Seventy-four of the technicians interviewed could remember seeing external fixation devices, but were unable to quantify how many were removed annually. Sixty-one of those questioned stated that they personally removed the fixator, three always requested an Orthopaedic surgeon to remove the device and five contacted a Nurse Specialist. Forty-eight stated that they returned the devices to their local Sterile Services Department or Orthopaedic department. Nine technicians always discarded the fixators, eight always left them with the body and two stored them in the mortuary. Many reusable external fixation devices are inappropriately disposed of each year due to a lack of knowledge and communication with Orthopaedic departments. Confusion also exists among some technicians over whether external fixation components should be treated as 'implants'. There is a need for clear guidelines to raise awareness and ensure the appropriate return of these high cost devices.

Measuring spirituality, religiosity, and denial in individuals working in funeral service to predict death anxiety.

The aim of the present study was to examine predictors of death anxiety in U.S. funeral directors/embalmers who were part of a larger study (n = 234). Backward stepwise multiple regression was conducted to determine whether or not spirituality, intrinsic religiosity, extrinsic religiosity, and denial predicted levels of death anxiety. Results indicated that spirituality along with age of the participants accounted for 19% of the variance of death anxiety, R2 = .190, R2(adj) = .180, F(2, 168) = 19.64, p < .001. Intrinsic religiosity, extrinsic religiosity, and denial were not significant in the regression model. Several items, however, in the model had a significant positive correlation with each other at the .01 alpha level including spirituality with intrinsic religiosity (r = .63) and age (r = .21), and intrinsic religiosity with denial (r = .22) and age (r = .24). Other variables correlated negatively with one another at the .01 alpha level. Namely, death anxiety with spirituality (-.38), intrinsic religiosity (r = -.36), and age (-.28); spirituality with extrinsic religiosity (-.22); intrinsic religiosity with extrinsic religiosity (-.45); and extrinsic religiosity with age (r = -.19). Limitations of the study and implications for practice were discussed.

Life expectancy of the 20th century Venda: a compilation of skeletal and cemetery data.

Little information is available on the 20th century mortality rates of rural black South African groups, such as the Venda. The purpose of this study was to apply abridged life tables in order to estimate life expectancy from both skeletal remains and death registry information of modern South African communities. Comparisons were also made with prehistoric and contemporary groups as a means to better evaluate life expectancy for this time period. The sample consisted of 160 skeletons of known Venda origin and burial registry information for 1364 black South Africans from the Rebecca Street and Mamelodi Cemeteries in Pretoria, South Africa. Standard anthropological techniques were applied to determine sex and estimate age from the skeletal remains. The stationary and non-stationary life table models were used to analyse the data. A high rate of child mortality, low juvenile and adult mortality with a steady increase in mortality after the age of 30 years was observed for both the Venda and the cemetery samples. Throughout the 20th century, life expectancy was shown to increase for black South Africans. However, due to the widespread HIV infection/AIDS of the 21st century, infant and young adult mortality rates continue to rise at such a speed that the decline in mortality seen for South Africans in the last 50 years will most likely to be lost in the next decade due to this disease.

Death anxiety in a national sample of United States funeral directors and its relationship with death exposure, age, and sex.

The purpose of this study is to examine the relationship between the level of death anxiety among a national sample of United States funeral directors with varying levels of death exposure, age, and sex. Utilizing the Multidimensional Fear of Death Scale (MFODS), the results showed a significant, but weak negative relationship between levels of death anxiety and the participants' reported number of funerals attended per year. The correlation between death anxiety scores and the number of reported embalming cases performed yearly was, however, not significant. We found a significant negative correlation between death anxiety and age in both men and women funeral directors. The difference in the death anxiety scores between men (n=166) and women (n=38) funeral directors was not significant. There was a significant negative correlation with age in both men and women in several fears of death including fear of the dying process, fear for significant others, and fear of premature death. The significant negative correlations were stronger for women than men across all three subscales. Results, direction for further research, and implications of the findings for mental health workers are discussed.

Postmortem interrogation and retrieval of implantable pacemakers and defibrillators: a survey of morticians and patients.

INTRODUCTION: Recent recalls of pacemakers and defibrillators cast a spotlight on product reliability. Universal postmortem device analysis could yield valuable information, but little data exist on the rate and feasibility of device examinations following death. This study investigated how morticians manage pacemakers and defibrillators and surveyed morticians and device patients regarding routine postmortem device interrogation and explantation. METHODS AND RESULTS: Seventy-one morticians were surveyed on device interrogation and explantation practices. One hundred fifty patients presenting for routine device interrogation were interviewed regarding preferences for what should be done with devices postmortem and willingness to execute "device advance directives" authorizing analysis and retrieval. The average number of devices annually explanted per mortician was 7 +/- 10 (range = 1 to 50). The most common methods of disposal were placement in medical waste (44%) and donation for human reimplantation in developing nations (18%). Only 4% of morticians reported ever returning devices to manufacturers, but 87% agreed that routine explantation and return of devices to manufacturers would be feasible. Eighty-seven percent of device patients had no understanding of how their device would be handled after death. However, a majority (82%) indicated a willingness to have their device interrogated after death, and most (79%) were willing to have it returned to manufacturers. Willingness was not associated with age, sex, time since device implantation, or device type. CONCLUSIONS: Implantable pacemakers and defibrillators are rarely analyzed after patients die. Systematic postmortem device retrieval appears feasible and acceptable to morticians and patients. Further efforts are needed to implement universal postmortem device evaluation.

A pilot study of an intervention to prevent negative mental health consequences of forensic mortuary work.

This preliminary study investigated an intervention to mitigate mental health effects of forensic mortuary work. Fourteen peer-nominated opinion leaders at two mortuaries were trained in traumatic stress management methods. Effect was examined on variables assessing stress management and effects of traumatic stress. Sixty-two staff members participated. At baseline, opinion leaders did not differ from their colleagues on any variable. After intervention, opinion leaders had significantly better scores in comparison to coworkers in leisure repertoire, problem solving, and positive states of mind, but no difference in use of avoidance or social support, or in interpersonal relationships. Qualitative data suggests that opinion leaders had increased self-awareness, improved ability to tolerate unchangeable stressors, and increased belief in their ability to make changes.

Pacemaker explosions in crematoria: problems and possible solutions.

The number of artificial cardiac pacemakers is increasing, as is the number of bodies being cremated. Because of the explosive potential of pacemakers when heated, a statutory question on the cremation form asks whether the deceased has a pacemaker and if so whether it has been removed. We sent a questionnaire to all the crematoria in the UK enquiring about the frequency, consequences and prevention of pacemaker explosions. We found that about half of all crematoria in the UK experience pacemaker explosions, that pacemaker explosions may cause structural damage and injury and that most crematoria staff are unaware of the explosive potential of implantable cardiac defibrillators. Crematoria staff rely on the accurate completion of cremation forms, and doctors who sign cremation forms have a legal obligation to provide such information.