Cemeteries

SECTION RISK PROFILE: CEMETERIES

1. SECTION        : CEMETERIES

2. ISTAT CODE      : 93.03

3. ISPESL CODE     :

SURVEY AREA

4. NATIONAL       :

5. REGIONAL       :

6. PROVINCIAL     : MILAN (metropolitan area)

7. USL                  : 6 USSL

8. SURVEY YEAR    : 1996

9. NUMBER OF EMPLOYEES

  9A. ADMINISTRATION    : 35 MALES

  9A. WORKERS           :307 MALES

10. NUMBER of ENTERPRISES: 7 CEMETERIES and CITY MORGUE

11. SURVEY STRUCTURE: ASL CITTÀ DI MILANO former USSL 38 - UOTSLL

12. REPORTING OFFICER

  STATUS    :

  NAME            : SUSANNA

  SURNAME   : CANTONI

  ADDRESS   : VIA RICORDI, 1

  POST CODE : 20131

  CITY            : MILANO

  PROVINCE  : MI

  PHONE     : 02/29505431

  FAX       : 02/29505430

  E-MAIL    :

13. ACCIDENTS     : TOTAL 340; FATALITIES: NONE

14. OCCUPATIONAL DISEASES

TYPE	Number of CASES	INAIL CODE

FOOTNOTE:

ACCIDENTS FROM 1985 TO 1996. THE ISTAT CODE REFERS TO THE FUNERAL SERVICE AND RELATED ACTIVITIES. THE MORGUE ACTIVITY CODE IS UNAVAILABLE. ACCIDENTS ARE DESCRIBED IN THE ENCLOSED DOCUMENT “ACCIDENT ANALYSIS”

ACCIDENT ANALYSIS

The accident analysis includes events which occurred in the 7 Milan metropolitan area cemeteries: Lambrate, Maggiore, Monumentale, Greco, Baggio, Chiaravalle, Bruzzano and in the City Morgue in the years from 1985 to 1990 and from 1991 to 1996.

The accident analysis was performed using the accident registers of the entire section. Such registers prevailingly enclose data relating to accidents with a prognosis exceeding three days. Consequently the actual number of accidents is likely to be greater than the reported number.

A total of 340 accidents occurred during the overall 12 year period. The following is the accident/cemetery break down:

Baggio: 11 accidents

Bruzzano: 49 accidents

Chiaravalle: 19 accidents

Greco: 12 accidents

Lambrate: 26 accidents

Maggiore: 154 accidents

Monumentale: 59 accidents

Morgue: 10 accidents

A total of 202 accidents occurred during the period 1985-1990. During the same period the average attendance of all employees (cemeteries and Morgue) was 425 employees/annum.

The calculated frequency index (F.I.) is:

                             202   x 1.000.000

              F.I. = -------------------------------- = 45,7

                       4.422.000 extrapolated working hours

A more detailed assessment was made on the last three-year period by virtue of more accurate data concerning actual number of hours worked.

During the three-year period 1994-1995-1996, 57 accidents occurred.

Average employee attendance for the period was 233 employees/annum.

The frequency index is:

                             57   x 1.000.000

              F.I. = -------------------------------- = 47

                       1.213.016 extrapolated working hours

Please note that the cemetery section F.I. remains relatively stable around the 45-47 mark.

A comparison of the FIs of other economic sectors, based on INAIL 1992-1993-1994 data shows the following results:

BUILDING CONSTRUCTION = 52,5 approx. (mean values)

ENGINEERING = 38,5 " "

TRANSPORT = 34 " "

CHEMICAL = 30 " "

TEXTILES = 21 " "

A comparison of the various FIs indicates that cemetery-section accidents are ranked second to those of the building construction section (F.I.= 52.5), notoriously top ranked. Cemetery-section FIs are substantially higher than Engineering (F.I.= 38.5) and those relating to the other sectors listed above.

Accidents have been grouped on the basis of the work cycle phases within cemetery-related activities (see: Chart 1). Data analysis shows that the “burial” phase reports the highest number of accidents (28.8%); ”exhumation” accounts for 21.7% and “corpse transfer” (8.8%).

WORK PHASE	TOTAL ACCIDENTS	%
CORPSE TRANSFER	30	8,8
NICHE BURIAL	2	0,6
EXHUMATION	74	22
INTERMENT BURIAL	98	29
MORGUE ACTIVITIES	10	2,9
CREMATION	4	1,2
NICHE EXHUMATION	2	0,6
OTHER	66	19
IN TRANSIT	9	2,6
LANDSCAPING	45	13
TOTAL	340

CHART 1:

Total number of accidents from 1985 to 1996 and work phase aggregate breakdown.

The substantial number of accidents (120) not assignable to any specific work cycle phase have been reported as Other, In-transit and Landscaping.

Item “Other” includes all accidents that occurred during job breaks (e.g. changing room, meals) and during transfers within cemetery limits.

Item “In-transit” includes events such as road accidents that took place while employee was in-transit from home to work.

Item “Landscaping” includes all accidents that occurred during general grounds maintenance activities (e.g. pruning of trees/bushes, etc.).

Mean job non-attendance periods, directly related to accident severity, have been calculated per work cycle phase (see Chart 2). Duration of job non-attendance periods range from 15 days for the “Morgue-related activities” work phase to 1.5 days for the “niche burial” work phase. In general accidents are of the non-severe type.

Work phase	Number of Accidents	Mean duration (working days)
Morgue-related activities	10	15.01
Interment burial	98	14.06
Cremation	4	11
Corpse transfer	30	9.04
Exhumation	74	10.02
Niche exhumation	2	2
Niche burial	2	1.05
Other	66	16.01
Landscaping	45	12.05
In-transit	9	36.3

Total	340

Chart 2:

Total number of accidents from 1985 to 1996: work phase aggregate and mean non-attendance duration breakdown

Chart 3 reports lesion type and respective frequency of occurrence. An analysis of the lesion types confirms that lesions are not severe.

LESION TYPE	TOTAL	%
CUTTING INJURIES	77	23
CONTUSION INJURIES	153	45
LUMBAGO	55	16
FRACTURE INJURIES	8	2,4
ALLERGIC OEDEMA	11	3,2
CORNEAL LESIONS	15	4,4
SKULL TRAUMAS	6	1,8
CHEMICAL BURNS	2	0,6
NON-DEFINED	12	3,5
TOTAL	340

Chart 3:

Total number of accidents from 1985 to 1996 and lesion type.

Item “Cutting injuries” includes all skin lesions: abrasions, grazes, puncture/slash and lacerated-contused wounds. Item “Contusion injuries” includes all contusion, sprain, dislocation, crushing and miscellaneous lesions. Item “Lumbago” includes all acute lumbago and muscular sprains. Item “Corneal lesions” includes all eye abrasions and lesions.

An analysis shows that “Contusion injuries” are the prevailing job-related lesion type, accounting for 45% of the total followed by “Cutting injuries”(23%) and by "Lumbago"(16%).

In considering the data set, it is quite likely that events such as soiling/staining, biologic liquid spurts, cuts and lumbago that have not resulted in a prognosis being released and hence non-attendance, have not been reported: Such events are nonetheless extremely important for safety hazard risk assessment purposes. With respect to “Lumbago”, it is likely that certain events have not been recorded as they were considered as illnesses and not as occupational accidents. The work anamneses collected by CEMOC –Centro di Medicina Occupazionale e di Comunità-Centre for occupational and community medicine) during the performance of the study quoted in the “Expected injury” chapters, indicate that a large number of individuals complained of instances of acute “Lumbago” during their working careers (18-20%) .

For certain work cycle phases that generate the largest number of accidents (exhumation, interment burial and corpse transfer) a listing has been made of those tasks that most frequently produce accidents (see Charts 4,5 and 6).

EXHUMATION TASKS	Accident SUB TOTAL	%

COLLECTION OF REMAINS	14	18,9
SITE PREPARATION	17	23
TOPSOIL REMOVAL	9	12,2
EXCAVATION PREPARATIONS	6	8,11
TOMBSTONE REMOVAL	1	1,35
REMOVAL ORNAMENTAL STONEWORK	3	4,05
TIMBER DISPOSAL	2	2,7
CASKET RAISING	2	2,7
ZINC COFFIN TRANSFER	2	2,7
WASTE DISPOSAL	4	5,41
SUNDRY	11	14,9
NON-DEFINED	3	4,05

TOTAL	74

Chart 4:

Exhumation- total number of accidents and job tasks

INTERMENT BURIAL TASKS	SUB TOTAL	%

EXCAVATION PREPARATION	31	31,6
SITE PREPARATION	40	40,8
CASKET LOWERING	14	14,3
GRAVE CLOSURE	3	3,06
CASKET CUTTING	3	3,06
DESCENT into EXCAVATION	1	1,02
CASKET HANDLING	1	1,02
CASKET TRANSFER	2	2,04
SUNDRY	3	3,06

TOTAL	98

Chart 5:

Interment burial – total number of accidents and job task

TRANSPORT/TASKS	SUB TOTAL	%

CASKET UNLOADING	10	33,3
CASKET LIFTING	6	20
CASKET TRANSFER	9	30
WREATH TRANSFER	2	6,67
SUNDRY	3	10

TOTAL	30

Chart 6:

Corpse Transport – total number of accidents and job tasks

A more detailed accident analysis was not performed due to lack of data apt to quantify the activity for the entire reference period (exhumations, interment burials, etc.). The unavailability of such data does not allow significant incidence values to be established such as to generate a hazard index.

1. WORK CYCLE PHASE            : CORPSE TRANSFER

2. INAIL CODE           : 93.03

3. HAZARD FACTOR        :

4. HAZARD CODE          :

5. Num. of EMPLOYEES    : 71 SEXTONS  and 196 CEMETERIAL STAFF

Chapter 1 - "Work Phase Description"

This work cycle phase includes all corpse handling (washing, dressing) and casket transfer operations from the original loading to the final handover point and more specifically:

1. casket transfer from original assignment location (home, hospital, morgue) to the cemetery is handled by operators called “sextons”;

2. casket transfer within cemetery bounds for interment burial, niche burial or cremation is handled by operators called “cemeterials”;

3. Morgue staff performs corpse handling from the roadside or other locations, including home and transfer to the morgue for autopsy purposes. Operations will be described in detail in the section titled “Morgue-related Activities”

In the first case the corpse is washed, dressed and placed in the casket prior to being transferred manually to the funeral vehicle. Manual casket handling (corpse and casket) from the original assignment location to handover at the cemetery is performed by four operators depending on weather conditions and staff availability. Specifically, casket handling along stairways is performed by four operators, one placed in front and three behind.

Casket transfer entails initial manual casket lifting, shouldering and transport to the funeral vehicle, loading operations using the vehicle’s tray and roller sliding load bed.

There are various procedures for casket transfer within cemetery bounds depending on burial type (interment, niche or cremation).

Different interment burial procedures are employed depending on the width of the plot access paths and the ground features:

1) the funeral vehicle reaches the perimeter path of the burial plot and the casket is manually transferred to the grave site;

2) the funeral vehicle reaches an area close to the burial plot, the casket is manually placed onto an appropriate push trolley and transferred to the grave site. Where ground conditions do not allow the use of a push trolley, transfer operations are performed manually by six operators.

The casket is then positioned on wood planks placed across the trench.

For niche burials, the funeral vehicle delivers the casket as close as possible to the entrance of the columbarium site. Quite often the columbarium is a multi-storey structure including one below ground and one or more above-ground levels.

Four operators manually transfer the casket from the funeral vehicle onto the push trolley by sliding it off the rear of the vehicle load bed. The load bed is fitted with a sliding tray and rollers.

If the niche is located on the structure’s ground floor, the push trolley is transferred directly to the niche. If climbing or descending is involved (from a few steps to one or more flights), the casket is again shouldered and transferred along the flight of stairs.

Four operators perform the operation. A fifth operator, positioned at the casket’s sloping end, stabilizes and manually supports the casket.

In certain cemeteries lifts/hoists are employed to transfer the casket to the desired vault storey.

In case of cremation, the casket is raised by four operators from the funeral vehicle load bed and placed on a push trolley. The trolley is then rolled to the cool storage rooms or to the lift/hoist for transfer to the refrigerated cells located on the lower level.

The casket is raised by four operators from the push trolley and placed on trestle stands in the cool storage rooms. Alternatively the operators place the casket in the refrigerated cells.

Prior to cremation the casket is transferred from the refrigerated cells to the cremation hall using a push trolley. The casket is then transferred from the trolley onto an 18-20 centimetre high handcart and pushed manually to the cremation furnace.

Occasionally the caskets awaiting niche or interment burial station in the cemetery storage halls. Often protracted casket stationing occurs, ranging from a few days to various months for a variety of reasons (e.g. awaiting tomb construction).

This procedure entails, especially in the warmer months, the generation of foul-smelling putrefaction gases in addition to the possibility of liquids filtering from the casket. This generates particular discomfort to the operators as they perform their job tasks within the storage areas.

The hygiene and structural conditions of the halls have been found to be extremely wanting as the premises have:

q non-washable floors and walls;

q insufficient ambient air circulation;

q no conditioning systems;

q no disinfectant and detergent devices.

Upon completion of each transfer operation, vehicles, tools and non-disposable PPEs are cleaned. Cleaning is performed manually on an unprogrammed basis without specific procedures concerning washing and decontamination operations.

Throwaway PPEs are disposed of in urban waste collection bins.

Operators at their own cost wash work clothes.

Chapter 2 - "Equipment and machinery"

· push trolleys are used to transfer the corpse from original assignment location to the van and from the funeral vehicle to the interment, niche burial sites or cremation hall.

· Funeral vehicle

This equipment is not subject to “EC marking” as it does not fall within the definition of “machine” as envisaged by the “Machine Directive” DPRn°459/1996.

The equipment used is prevailingly very old and in badly kept condition.

Chapter 3 - "Hazard factor"

Safety hazards encountered during the various transport phases due to structural features of the in-door/out-door working environment and to the loads handled:

· falling/sliding hazards due to ground irregularities or the presence of fixed external steps;

· falling, shock, sliding hazards due to load handling operations being performed within restricted confines (passageways, stairways and landings, etc.);

· crushing hazards due to slippage of loads being handled.

Personal hygiene-environmental hazards due to the presence of chemical, physical and biologic agents:

· chemical agent hazard due to the handling of disinfectants and detergents employed during equipment, work surfaces and PPEs cleaning operations;

· physical agent hazard due to exposure to inclement weather conditions during the performance of all outdoor activities;

· biologic agent hazard due to the handling of or contact with objects or work surfaces soiled by potentially infected biologic fluids coming from the corpses (HBV-HCV-HIV).

Transversal or organizational hazards due to the nature of the transport and load being handled:

· ergonomic-related hazards due to manual handling of loads up to 200 kilograms (casket, zinc coffin, corpse);

· ergonomic-related hazards due to odd working postures and the need to exert noticeable physical effort in case of uneven ground, cramped indoor work spaces and insufficient number of operators (job task organization);

· general health hazards and physical discomfort due to working environment conditions (foul-smelling breathing air, decomposition gases, biologic fluids filtering from caskets);

· psychological factors related to the item being handled and to the scant social recognition for the tasks performed.

Safety hazard estimates are furnished in the chapter dealing with general accident trends. Accident analysis has been performed employing accident registers relating to the entire sector during the years from 1985 to 1996.

Personal hygiene-environmental hazards due to the handling of disinfectants and detergents may become significant because of the lack of specific instructions and procedures for the performance of cleaning and decontamination operations on materials and equipment.

Exposure hazards to extreme weather and temperature conditions are significant due to organizational shortfalls leading to lack of/unsuitability of protective clothing.

The above hazards may not be readily quantified.

The biologic agent hazard deriving from handling of the corpse and contact with fluids filtering from the casket caused by initial decomposition is high as far as HBV and HCV are concerned especially when PPEs are not properly used. The high hazard is due to the virus’ protracted survival even in an external environment and its high contamination levels.

HIV contamination hazard is highest in the initial post-fatality hours. Subsequently contamination hazard tends to decrease because of the relatively lower infectivity and the virus’ reduced environmental survival. Thus, excluding the initial post-fatality hours, the HIV hazard likelihood is lower though its severity remains nevertheless relatively high.

In 1990 and again in 1993, all sexton and cemeterial staff were subjected to blood test in order to assess exposure to biologic hazard (- markers HBV (1990-1993) and HCV (1993)-).

During corpse transfer, in addition to lumbar overloading, many operations involve:

q highly asymmetric loading of the dorsolumbar tract of the rachis;

q asymmetric and rotational rachis loading;

q direct load bearing by the shoulder and resulting hardship sustained by the upper trapezius muscular structure, cervical rachis tract and associated degenerative phenomena of the acromioclavicular and scapulohumeral joints.

An analysis of working conditions identified numerous instances of high mechanical overload of the entire locomotor apparatus and especially of the lumbar rachis. Axial compression levels are frequently higher than the first safeguard threshold (350 kgs) and occasionally exceed the maximum tolerable threshold level (650 kgs).

Overload situations for operators tasked with this work cycle phase vary depending on daily personal task distribution and transport operation frequency (sextons: approximately 3000 funerals/annum; cemeterials: approximately 11,500 including cremations, interment and niche burials).

Acute and chronic spinal column pathologies were studied using clinical functional rachis composition protocols established by the EPM research unit (Ergonomia della Postura e del Movimento- Ergonomics of Posture and Motion), Milan.

The protocols incorporated also various other clinical tests, prevailingly X-ray tests, for more precise diagnosis definition of specific cases.

A hazard estimate of the psychologic hardships is not readily assessable due to the lack of specific studies.

Chapter 4 - "Expected Injuries"

· Sprains, contusions, fractures, cuts and lacerated/contused wounds, crushing injuries due to safety hazards;

· Eczemas, dermatitis, allergopathies caused by use of detergents and disinfectants (chemical agents);

· Colds caused by working outdoors (physical agents);

· Parenterally transmitted biologic agent infections (HBV, HCV, HIV);

· Acute lumbosciaticas, muscular sprains, cervical/dorsal/ lumbosacral spondyloarthropathies (SAPs) caused by handling of heavy loads and to odd working postures;

· Psychological hardship

Report of detected injuries

The accident trend is described in the aforementioned chapter.

No data relating to potential injuries caused by chemical and physical agents was found.

Blood test results relating to biologic exposure hazard (HBV and HCV markers) performed in the period 1990-1993 show that 35% of sextons and 46% of cemeterial staff tested positive to at least one marker.

Studies performed on other worker groups not particularly exposed to biologic hazard (e.g. municipal police officers) produced positive results in 20% of cases.

During the time period 1990-1993 3 new HBV infection cases were recorded for morgue staff (out of 43 non-immune operators) and 2 new cases for cemeterial staff (out of 126 non-immune operators). Five individuals that had tested negative to all markers during 1990, tested positive in 1993 to HBsAb and/or HBeAb and/or HBcAb markers.

Workers were subsequently subjected to hepatitis B vaccinations.

The following data results from the medical tests to which sextons and cemeterial staff was subjected to by CEMOC (Centro di Medicina Occupazionale e di Comunità-Centre for occupational and community medicine) in 1990-1991 and 1992-1993, with respect to injuries deriving from the handling of heavy loads, odd working postures and high physical exertion.

Tests performed during the period 1990-1991 refer to 89 sextons and 280 cemeterial staff. Tests performed during the 1992-1993 period refer to 90 sextons and 257 cemeterial staff.

Data shows a particularly high percentage of individuals affected by acute lumbago. The number of workers complaining of substantial episodes of acute lumbago in the course of their working life totals 18% for sextons and 20% for cemeterial staff. Acute lumbago episodes that occurred in the year prior to the visit totalled 4.5% for sextons and 8.5% for cemeterial staff.

The above data shows a prevalence of cervical SAP (21.3% for sextons and 12.9% for cemeterial staff), dorsal SAP (19.1% for sextons and 11% for cemeterial staff) and lumbosacral SAP (27% for sextons and 25% for cemeterial staff).

Data thus shows that sextons manifest a tendency to cervical, dorsal and lumbar rachis complaints from two to three times greater than workers not exposed to manual load handling hazards. Cemeterial staff manifest a particularly high tendency to lumbar rachis complaints with respect to workers not exposed to analogous hazards.

A comparison of data sets shows that acute lumbago hazards are significantly greater for cemeterial staff (related to intense, short-duration exertion) while cervical, dorsal and lumbar rachis pathologies are greater for sextons (related to the frequency of hazardous operations).

Data was confirmed by checks performed during 1992/1993.

Chapter 5 - "Preventive Measures"

The top priority action is the adoption of work procedures relying on the introduction of mechanical aids in order to eliminate or reduce accidents and the ergonomic hazards due to manual handling of caskets.

The action has not been as yet implemented as various hypotheses and/or proposals are currently being reviewed.

Potential solutions are often influenced by deep rooted cultural beliefs relating to mechanized handling of the caskets as well as by practical difficulties in adapting existing handling devices (e.g. automated lifting devices used by removals firms) to the specific requirements of casket handling and, last but not least, the scant financial resources of agencies or firms.

Actions so far implemented have prevailingly focused on the issue of new equipment and specific PPEs. These actions have consequently impacted on biologic, accident and chemical hazard limitation.

Specific PPEs have been issued relating to various transfer-related activities including non-slip, steel capped footwear; disposable Tyvek water-proof coveralls; latex and leather hand gloves; face masks. Staff PPE information and training programmes have been implemented.

Operators have been informed and trained with respect to equipment washing and decontamination hazards, proper use of specific PPEs and frequency/methods for washing/decontamination of equipment, materials, motor vehicles and reusable PPEs.

The creation of a specific cleaning and decontamination area for equipment and reusable PPE has been made mandatory. The area must include running water outlets, rubber footwear soaking tanks and washbasins fitted with lever or foot-operated faucets, liquid detergent and disposable hand towel dispensers.

In order to counter biologic agent hazards all corpses are considered as potentially infected. Consequently operators have been instructed to implement specific procedures and precautions during corpse and soiled equipment handling operations.

A hepatitis B vaccination campaign has been implemented.

Work clothes/uniforms shall be laundered by the Administration in centralised facilities.

Wastes (materials and disposable PPEs) generated during operations involving contact with corpse materials shall no longer be treated as normal urban wastes but as special wastes requiring dedicated “special waste containers”. Such containers shall be stored in adequately ventilated premises with readily washable, waterproof floor and wall lining materials.

With respect to load handling hazards, in addition to the above-mentioned PPEs, the only measure implemented has been that of declaring operators with certified rachis pathologies as temporary or permanently non-fit for load handling duties.

In 1990 non-fitness for load handling duties (temporary or permanent) involved 14 sextons and 40 cemeterial staff (respectively 17.1% and 14.5% of all operators tested). In 1992 non-fitness involved an additional 17 sextons and 47 cemeterial staff (respectively 19.8% and 17.7% of all operators tested).

With respect to hardships caused by structural/hygiene working conditions in the storage areas, specific instructions were issued as to the measures to be implemented: air conditioning systems (rapid exhaust of decomposition gases); adequate cooling systems (refrigerated cells for corpse preservation); wash/decontamination of floors and walls; wash basins with lever/foot-operated faucets.

Instructions were issued, during the performance of the study, with respect to the organization of work tasks with specific reference to the number of operators involved during transfer operations. Data on the current implementation of such measures throughout the sector are not available.

Information and training on load handling methods is essential. No such programmes have as yet been implemented.

Chapter 6 - "Outsourcing"

The preparation of the corpse for the funeral service and all phases of transport may be subject to outsourcing procedures. Funerals managed directly by private companies fall within this class.

Every year approximately 15,000 funerals take place within the territorial jurisdiction of the Municipality of Milan, approximately 20% are handled by the Municipality itself.

Chapter 7 - "Legislative References"

The hereunder listed legislative and bibliographic references relate to all the phases of the entire working cycle.

· D.P.R.n°547/1955 – Workplace Accident Prevention Rules

· D.P.R.n°303/1956 – General Workplace Hygiene Rules

· D.P.R.n°164/1956 – Construction site accident prevention Rules

· D.Lgs.n°277/1991 – Implementation of Directives n°80/1107/EEC, n°82/605/EEC, n°83/477/EEC, n°86/188/EEC and n°88/642/EEC relating to protection of workers from chemical, physical and biologic exposure hazards pursuant to Article 7 of Law n°212, dated 30 July 1990

· D.Lgs.n°626/1994 and subsequent amendments – Implementation of Directives n°89/391/EEC, n°89/654/EEC, n°89/655/EEC, n°89/656/EEC, n°90/269/EEC, n°90/270/EEC,n°90/394/EEC and n°90/679/EEC relating to the enhancement of worker safety and health

· D.Lgs.n°475/1992 – Implementation of Council Directive 89/686/EEC dated 21/12/1989 relating to harmonization of member states’ legislation concerning personal protection equipment

· D.P.R.n°459/1996 – Implementation regulations for Directives n°89/392/EEC, n°91/368/EEC, n°93/44/EEC and n°93/68/EEC relating to harmonization of member states’ legislation concerning Machinery

· D.Lgs.n°494/96 – Implementation of Directive n°92/57/EEC relating to minimum safety and health requirements for temporary or mobile construction sites

· Municipal building and health regulations

· D.P.R.n°285/1990 – Approval of Mortuary police Regulations

· Municipal Mortuary police Regulations

· Law n°292 dated 05/03/1963 (Mandatory anti-tetanus vaccination)

· D.M. 26/04/1990 and D.M. 04/10/1991 (Identification of risk groups for Hepatitis B virus vaccination)

· D.P.R.n°203/88 – Implementation of Directives n°80/779/EEC, n°82/884/EEC, n°84/360/EEC and 85/203/EEC concerning air quality regulations relating to specific pollution and polluting agents produced by manufacturing facilities pursuant to Article 15, Law n°183 dated 16/04/1987

· D.Lgs.n°22/1997 and subsequent amendments – Implementation of Directives n°91/156/EEC concerning waste disposal, n°91/689/EEC concerning hazardous wastes and n°94/62/EEC concerning packaging and packaging wastes

· Ministry of Health Circular issued 20/06/1983 n°57: Formaldehyde Uses: hazards deriving from formaldehyde use.

· D.Lgs.n°626/1994 Legislative Decree Application Guidelines issued by Autonomous Regions and Provinces Coordination Agency, October 1996

· Ministry of Health – National AIDS Commission – Guidelines to health operators for HIV infection control, Rome 06/09/1989

· Law n°135 dated 05/06/1990 – Programme of urgent AIDS prevention and counter measures

· Ministry of Health Decree dated 28.9.1990 – Rules concerning professional HIV infection protection in public and private hospitals and health service facilities

· NIOSH: "Work practices guide for manual lifting", NIOSH Technical Report n°81-122. U.S., 1981

· Proceedings of 1^st National Seminar “Occupational hazards in certain least developed tertiary sectors (solid urban wastes, funeral services, supermarkets)” – SNOP – Milan, 23 May 1994

· Proceedings of 1^st Seminar “Public Administration and Legislative Decree n°626” – SNOP – Turin, 30 & 31 May 1996

· Occhipinti, Colombini, Cattaneo, Cervi, Grieco – Work postures and rachis alterations in funeral service operators - Med. Lav. - 1988, 79: 6

· American Conference of Governmental Industrial Hygienists (ACGIH) - Threshold limit values for chemical substances 1995-96

· International Agency for Research on Cancer (IARC) - Monographs on the evaluation of carcinogenic risk to humans.

Chapter 8 - "Environmental hazards"

The environmental hazards of this work phase relate to the disposal of wastes generated by tasks involving contact with corpse materials.

Measures implemented for the handling of such wastes as “special waste materials” have limited and controlled this class of hazard.

Currently such special wastes are adequately sealed and disposed of by incineration or decontaminated employing autoclaves prior to disposal.

1. WORK CYCLE PHASE            : AUTOPSY

2. INAIL CODE           : 93.03

3. HAZARD FACTOR        :

4. HAZARD CODE          :

5. Num. of EMPLOYEES    : 71 SEXTONS and 196 CEMETERIAL STAFF

Chapter 1 - "Work Phase Description"

Morgue activities involve various operations, some of which fall within the sphere of forensic medicine, such as postmortem examination. They are performed by university-employed staff (physicians) and by municipality-employed staff (nursing-paramedical). Other operations, such as corpse and assorted materials handling, are performed by morgue staff employed solely by the Municipality.

The following work phase description refers to those operations performed by municipality-employed staff generally referred to as morgue staff, independently of professional qualifications. Tasks performed by other staff in the dissection room (physicians and nursing-paramedical) are only referred to incidentally.

The following description refers to the tasks performed at the time of the initial study (1990) in extremely dangerous premises characterised by structural shortfalls. More specifically, working premises were small and confined, insufficiently ventilated, lacking appropriate separation between the various work areas, equipped with frequently inefficient refrigeration cells, obsolete machinery, badly positioned wash basins and water outlets and difficult to clean, cracked floor and wall surfaces, potential nestling sites for biologic agents.

Structural and equipment innovations and currently implemented procedures are described in the preventive measures chapter (see under). Such procedures have also been subsequently radically modified.

Morgue-related activities:

· Collection, undressing, dressing and diverse corpse handling operations within and outside the morgue;

· Wash/cleaning of equipment and premises;

· Collection and disposal of soiled linen and wastes;

· Support to postmortem examination.

Morgue staff performs corpse collection from roadside accident site or from home. The corpse is placed in a bag or if acknowledged as contaminated, in disposable plastic bags. Depending on weather conditions and staff availability, 2,3 or 4 operators handle the corpse; generally if corpse handling involves descending stairs, one operator is placed in front and two at the rear.

The corpse is manually carried to a trolley equipped with a steel tray fitted with carrying handles. The trolley is pushed to the vehicle and transferred to the morgue.

Not all vehicles are equipped with a washbasin and containers for special wastes (disposable gloves, coveralls, etc.)

At the morgue, the corpse and trolley are pushed to the observation room. The corpse is either kept under observation for 24 approximately hours or placed directly in the refrigerated cells awaiting the results of the postmortem examination.

Morgue refrigerated cells cause certain difficulties to operators as some are too short to store the corpse while others are positioned at a height that entails the use of a ladder, as adequate lifting systems are not available.

The absence of conservation systems for the corpses that may not be stored in the refrigerated cells, has resulted in corpses in advanced state of decomposition being stored in adjacent rooms. The cell refrigeration system is obsolete and frequently breaks down. Due to the lack of regular maintenance, breakdowns are often repaired after considerable time has elapsed. Frequently various cells are not actively refrigerated thus resulting in accelerated corpse decomposition.

Depending on operators’ discretion, cells are cleaned rarely using a flexible water hose.

The overall result of all these shortcomings is that foul-smelling odours are generated and spread throughout the whole building. In addition, the conditions favour the growth of numerous Sarcophaga carnaria larvae and adult flies in the corpse storage rooms, including the refrigerated cells.

For postmortem examinations, morgue staff transfer the corpse and the steel tray from the refrigerated cell onto a trolley. The trolley is then pushed to the examination room where the corpse is manually placed on the examination table. During the performance of the postmortem, morgue staff assist the physicians and nursing-paramedical staff in handling the corpse.

Once the postmortem examination is completed, staff place the washed corpse onto the carrying tray and, using the trolley transfer the corpse to the dressing room where it is dressed prior to being placed in the casket.

Morgue staff are tasked with cleaning the equipment used during the examination.

The cleaning operations of transport vehicles, refrigerated cells, observation room and dressing room are performed at operators’ discretion without following any specific procedure as to the methods or frequency.

Steel corpse carrying trays are washed outdoors using running water (delivered by a flexible hose) and detergents. Runoff water spreads on the yard surface, as there are no specific collection drains. Steel trays are left to dry in the yard.

For the performance of these duties operators are issued with waterproof overalls and short rubber gloves. They are not issued with appropriate footwear (boots/shoes) nor can they adequately protect their arms from spray and contact with liquid detergents.

Disposable PPEs (gloves, coveralls), employed during corpse transfer operations involving motor vehicles, are often disposed of as standard urban wastes due to the unavailability of appropriate special waste containers.

Disposable PPEs and special wastes generated in the examination room are collected in plastic bins and subsequently disposed of as special wastes.

Soiled linen (sheets, hand towels, coveralls) are retrieved by operators from wooden collection boxes and placed in cloth bags; soiled linen used on contaminated corpses is placed directly in polythene bags.

The soiled linen is sent to a municipal decontamination facility and then to a laundry/pressing plant approved by the National Health Service.

The walls of the postmortem examination room are lined with tiles up to a height of approximately 2 metres. Windows provide ambient ventilation.

Furnishings include two steel examination tables equipped with washbasins and wooden dunnage platforms, metal tables and plastic bins for special wastes collection. The room has two washbasins with standard handgrip faucets for operator use; solid soap bars rest on the edge of the basins. Operators dry their hands using non-disposable, fabric hand towels.

Non-specialised nursing-paramedical staff assist physicians during the postmortem examinations and preserve sample tissues in formalin. They also perform cleaning operations of the equipment and premises after the examination.

Floor surfaces are cleaned using sodium hypochlorite solution. No complete decontamination of the premises and general furnishings has ever been performed.

Cleaning of surgical instruments is performed under running water only in the basin of the examination table. Coveralls worn by nursing-paramedical staff are used to dry equipment. Electric-powered equipment (e.g. portable saws) are not adequately cleaned and decontaminated due to the equipment’s poor insulation.

For autopsies performed on clearly infected corpses, the surgical instruments are rinsed in water and then placed in a sodium hypochlorite solution (unspecified concentration and immersion times). Instruments are then subsequently soaked in 10% formalin solution overnight.

Surgical instruments are never decontaminated due to non-availability of sterilizer containers notwithstanding the presence of an autoclave.

Morgue staff work clothes are washed by staff members themselves at home.

Chapter 2 - "Equipment and machines"

· Jute fabric bags for corpses

· Disposable plastic bags

· Steel corpse carrying trays (for trolleys and refrigerated cells)

· Trolleys for corpse transfer from collection site to motor vehicle and for all subsequent corpse handling operations within the morgue

· Motor vehicles (vans)

· Refrigerated cells

· Cotton sheets and towels

· Surgical instruments (lancets, saws, suture needles, surgical forceps, etc.)

· Examination tables equipped with wash basins

· Autoclave

All equipment is generally old and in an ill state of repair.

Equipment is not subject to “EC marking” as it does not fall within the scope of the “Machine Directive”-D.P.R.n°459/1996.

The autoclave, a pressurised vessel, is subject to ISPESL certification.

Chapter 3 - "Hazard factor"

Safety hazards due to the structural characteristics of the indoor/outdoor working environment, job task organization and characteristics of the equipment/instruments/tools:

· falling/sliding hazards due to ground irregularities or the presence of fixed external steps;

· falling, shock, sliding hazards due to load handling operations being performed within restricted confines (passageways, stairways and landings, etc.);

· falling/sliding hazards due to work performed at night during corpse recovery in unlit or badly lit conditions (e.g. parks, woods, etc);

· falling/sliding/crushing hazards due to slippage of loads being handled.

· lesion hazards due to the handling of cutting objects (e.g. saws, lancets, surgical forceps, etc.);

· electric shock hazard due to the handling of hand-held electric powered tools;

· general accident hazard due to the handling/use of equipment and tools.

Personal hygiene-environmental hazards due to the presence of chemical, physical and biologic agents:

· chemical agent hazard due to the handling of disinfectants and detergents employed during equipment, work surfaces and PPEs cleaning operations;

· chemical agent hazard due to inhalation of formaldehyde fumes (employed for decontamination of surgical instruments and for preservation of autopsy sample tissues) generated by the lack of adequate utilization and dilution procedures, local exhaust systems and appropriate PPEs;

· physical agent hazard due to exposure to inclement weather conditions during the performance of all outdoor activities;

· biologic agent hazard due to the handling of or contact with objects or work surfaces soiled by potentially infected soil and/or biologic fluids coming from the corpses (Tetanus-HBV-HCV-HIV) associated to potential cutting or piercing lesions;

· biologic agent hazard due to environmental pollution generated by autopsies performed on corpses with tubercular mycobacterium lesions.

Transversal or organizational hazards due to the nature of the transport and load being handled:

· ergonomic-related hazards due to manual handling of loads;

· general health hazards and physical discomfort due to working environment conditions (foul-smelling breathing air, flies decomposition gases, etc.);

· psychological factors related to the item being handled and to the scant social recognition for the tasks performed.

The personal hygiene-environmental hazard generated by the handling of disinfectants and detergents may be significant due to the lack of specific operating procedures and methods relating to cleaning and decontamination of materials or equipment used. Furthermore, with respect to formaldehyde use, the ensuing chemical hazard may be particularly significant due to the characteristics of the substance employed. Formaldehyde is listed by IARC as class 2A:”probable human carcinogenic agent” and by ACGIH as class A2:”suspected human carcinogenic agent”. As no dedicated studies have been performed with respect to the Milan Morgue, it is not possible to assess the hazard factor.

The physical agent hazard (severe weather conditions or extreme temperatures) also may be significant due to organizational shortcomings generated by lack of or unsuitability of protective clothing.

The entity of these hazards is not readily quantifiable.

The biologic agent hazard generated by contact with potentially contaminated materials is high with respect to HBV and HCV due to the virus’ lengthy survival period even in an external environment and its high contamination level. The hazard is determined by the non-utilization of suitable PPEs especially during corpse retrieval and transfer operations due to possible soiling. The hazard is also present in postmortem examination operations and is determined by possible cuts, lesions and splashes.

With respect to the HIV hazard, the theoretical possibility of contamination by fluids issuing from the corpses may not be excluded. The hazard is highest in the immediate post-death hours and progressively decreases due to the scarce contagion level and the virus’ reduced survival period in an outdoor environment. With the exception of the initial post-death hours, the HIV hazard probability is relatively low while its severity remains high. The hazard is greatest during corpse retrieval operations.

The Tetanus infection hazard is relatively low as a result of the extension of mandatory prophylaxis procedures to this class of operators.

In 1990 and again in 1993, all morgue staff were subjected to blood test in order to assess exposure to biologic hazard (- markers HBV (1990-1993) and HCV (1993)-).

The tubercular infection hazard is not readily quantifiable as no specific data is available in literature and no cases were detected in the course of our study. The detection of the tubercular mycobacterium in ambient air is difficult for technical reasons.

Infection exposure hazard data vary and are not easily found, as there are no specific detection procedures concerning accidents involving soiling, splash and contact with potentially contaminated organic materials.

Biologic hazard estimates vary depending on the type of operation performed (corpse transfer and/or postmortem examination room activities) and the frequency of such operations (1,156 transfers and 985 autopsies performed annually).

Overload situations involving operators during this work cycle phase vary depending on difficulties encountered during transfer operations (stairs, hard-to-access sites, weight and load grip), job task organization (number of operators involved) and frequency of operations (1,156 corpse retrieval/morgue transfers, corpse handling within morgue performed annually).

The protocols incorporated also various other clinical tests, prevailingly X-ray tests, for more precise diagnosis definition of specific cases.

An assessment of the fixed posture hazard to autopsy operators was not included in the study.

A hazard estimate of the psychologic hardships is not readily assessable due to the lack of specific studies.

Chapter 4 - "Expected Injuries"

· Sprains, contusions, fractures, cuts and lacerated/contused wounds, crushing injuries due to safety hazards;

· Eczemas, dermatitis, allergopathies caused by use of detergents and disinfectants;

· Eczemas, keratitis, conjunctival and respiratory tract mucosa irritations generated by use of formaldehyde;

· Colds caused by working outdoors (physical agents);

· Parenterally transmitted biologic agent infections (HBV, HCV, HIV and Tetanus);

· Airborne biologic agent infections (Tuberculosis);

· Acute lumbosciaticas, muscular sprains, cervical/dorsal/ lumbosacral spondyloarthropathies (SAPs) caused by handling of heavy loads, odd and stationary working postures;

· Psychological hardship

Report of detected injuries

The accident trend is described in the aforementioned chapter.

No data relating to potential injuries caused by chemical and physical agents was found.

Blood test results relating to biologic exposure hazard (HBV and HCV markers) performed in the period 1990-1993 show that 56.7% of morgue staff tested positive to at least one marker. Consequently, this worker group is exposed to a higher biologic hazard than other operators in this sector.

Studies performed on other worker groups not particularly exposed to biologic hazard (e.g. municipal police officers) produced positive results in 20% of cases.

No new HBV cases were detected between the initial health controls, performed in 1990, and the subsequent ones performed in 1993. All operators were subjected to hepatitis B vaccinations.

With respect to injuries deriving from handling of heavy loads, fixed and/or odd work postures and high physical effort, no further data is available as the worker group has not been subjected to specific health studies.

Chapter 5 - "Preventive Measures"

The principal preventive measure implemented has been the complete refurbishment of the morgue.

The measure has radically affected the architectural structure and involved building a new postmortem examination room, the creation of new work spaces, improved redistribution of interior space involving a net separation between “clean” and “dirty” work areas, installation of appropriate air conditioning and electric power distribution system conforming to current safety standards.

All equipment and fittings were replaced. New installations included: refrigerated cells, examination room furnishings, medical apparatus, surgical instruments. A new automated corpse handling system and steel carrying tray washing/decontamination system were installed. New work procedures were implemented relating to washing/decontamination of instruments and premises, formaldehyde handling, PPE cleaning, collection and disposal of special wastes, etc.

Measures implemented have resulted in an improvement of morgue staff indoor working conditions and consequent significant hazard reduction relating to safety, personal health/environment (chemical and biologic agents) and transverse/organization (manual load handling).

Nonetheless the above hazards are still present with respect to corpse retrieval and certain specific activities performed within the examination room.

The new air conditioning and ventilation systems have brought about a significant improvement of working environment conditions relating to airborne pollutants (fumes, odour, etc.) and microclimate.

The ventilation system ensures 6 environment air volume replacements per hour for all morgue rooms and 10-12 replacements/hour in the examination room. No environment air replacements are envisaged for all corpse-stationing areas, as air is exhausted through absolute filters fitted with active carbon elements, prior to being dumped to the outside environment.

Notwithstanding the above measures, foul odours in the examination room persist when activity affects corpses in an advanced state of decomposition. A requirement has been established to envisage additional ventilation for these specific working conditions.

All refrigerated cells have been located in a separate area that excludes the presence of staff. All cells are serviced by an automated handling system that allows corpse handling.

The installation of the automated system has eliminated manual load handling hazards within morgue premises and has significantly reduced instances involving operator contact with corpses, thus also reducing the biologic contamination hazard.

The automated system covers almost all morgue operations (in-coming/out-going corpse handling, corpse weighing, recording of interventions performed and autopsies, etc.).

The system includes:

· Automated warehousing trolley for corpse retrieval/storage from refrigerated cells;

· Magnetic band scanner and load station for automatic traversing trolleys;

· automatic traversing trolley including automatic load lifting device;

· control stations located in the examination and corpse observation rooms;

· corpse weighing station;

· corpse steel carrying tray end station;

· steel carrying tray wash/decontamination/drying/storage/distribution system (automated tray handling system);

· management/control and data recording computer.

The measures implemented have brought about a reduction of hazards deriving from the previous physical working premises but have generated a series of new, potential safety hazards.

New safety hazards include operators being potentially struck by the automated traversing trolley. In more general terms, hazards relate to all interactions between operators and automated power-assisted handling components, electrical shock hazards generated by electrical equipment and during cleaning operations involving internal/external surfaces of automated systems.

The following are the hazard prevention measures, some already partially implemented during equipment installation. The monitoring authority prescribed the following measures.

· Fixed protection fences and interlocked safety devices blocking operator access to the refrigerated cell area during automated corpse handling trolley traversing operations;

· Fixed protection fences shielding operator control console near the corpse weighing station;

· Photoelectric cells (“electric eye”) blocking the traversing trolley in case of operator access to the narrow passageway separating the refrigerated cells and the postmortem examination room;

· Visual/acoustic alarm signalling traversing trolley operations;

· Automatic traversing trolley blocking device in case of trolley striking an obstacle;

· Protection of the traversing trolley’s electrical circuits to allow cleaning and decontamination operations;

· Horizontal surface markings indicating traversing trolley operational area in the examination room and nearby premises;

· Automated closed-circuit washing system for steel carrying trays;

· Electrical system within refrigerated cells to IP65 and IP67 safety standard (lighting fixtures and cell hatch opening switch gear) to prevent electric shock hazard during interior cell surface cleaning operations;

· Water drainage of internal surfaces for refrigerated cell-washing operations.

In relation to work procedures, operators have been issued with disposable plastic corpse bags with three carrying handles for easier handling and specific PPEs (disposable Tyvek coveralls, non-slip footwear, rubber gloves, face masks, etc.).

Specific information and training programmes relating to proper equipment/PPE use have been implemented. All corpses are considered as being potentially contaminated. Consequently specific operating procedures have been issued to operators covering corpse handling and soiled equipment use.

Operators have been issued with specific instructions with respect to motor vehicle and non-disposable PPE cleaning/decontamination procedures. A requirement was issued relating to a dedicated area equipped with water outlet and soaking tanks for rubber footwear cleaning operations.

The steel corpse carrying tray cleaning/decontamination procedure has been completely automated (see above), thus eliminating operator exposure to biologic agent and manual load handling hazards.

Cleaning and decontamination of refrigerated cells and morgue premises have been subjected to outsourcing agreements. Firms have been issued with specific instructions with respect to frequency and operating procedures. Cleaning/decontamination procedures are still performed manually.

Refrigerated cell cleaning/decontamination is performed by operators accessing the area from passageways located at the rear of the cells. Operator access entails blockage of the traversing trolley for the duration of the cleaning/decontamination operations.

The operator employs a pressure nozzle dispensing automatically pre-mixed water/disinfectant to clean and decontaminate the refrigerated cell’s internal surfaces and carrying tray support devices. Cleaning fluids are collected and drained by means of dedicated plumbing to a processing system prior to being discharged to the local sewer system.

A microbiologic study was performed in order to assess the sanitation procedure efficiency. Study results have indicated a satisfactory decontamination level even though the need for further enhancements was detected, especially with respect to certain specific areas (e.g. refrigerated cells, steel carrying trays).

Work clothes are cleaned by centralized laundry plants at the Administration’s expense.

With respect to work procedures concerning postmortem examination activities, instructions have been issued to treat all organic fluids and tissues as potentially contaminated materials. Furthermore, in conformity with Ministry of Health guidelines, all operators shall implement and abide by the following mandatory specific work procedures:

· Smoking, drinking and eating are forbidden within the confines of the postmortem examination room;

· Operators with open or secreting lesions shall not take part in postmortem examinations;

· Observers shall wear protective clothing and shall be confined to the minimum contamination area;

· All operators (including morgue staff performing corpse preparation activities) performing any task within the examination room shall at all times wear the following PPEs: white coat, water-proof apron, gloves, face mask, protective eyewear/face shield;

· All operators performing the autopsy shall wear two pairs of intact autopsy gloves. Should gloves rupture, become soiled or be punctured (including cases where no laceration or abrasion of wearer’s skin tissue occurs), they shall immediately be removed and operator shall carefully wash hands prior to donning new gloves;

· Steel mesh gloves shall be worn during all operations involving rib cage removal, vertebrae removal, skullcap removal and while employing bone cutting implements;

· Exposed and jagged bone extremities shall be identified and covered using napkins or bone adhesive;

· Bone cutting operations shall preferably be performed using hand operated saws or bone milling cutters instead of electric powered tools in order to minimize the generation of airborne particles;

· Only those parts of the body (cranium, rib cage, abdomen, upper/lower limbs, etc) that are necessary to answer queries shall be opened; organs/tissues required to answer queries shall be removed and sectioned. The sectioning area shall be located close to the postmortem table so as to limit unnecessary transfers and subsequent soiling of surfaces. Brain tissue and spinal marrow examinations are not performed on a routine basis. Such examinations shall be performed solely pursuant to a specific request;

· Organs shall be sectioned following accepted procedures involving fixation of organs prior to performing further investigations. In cases of suspected pulmonary infections, lungs shall be insufflated using formaldehyde;

· Organs shall be handled with care and shall not be subjected to high pressure water rinsing in order to minimize the generation of aerosols. The organ washing area shall be located close to the examination table. It shall be easily accessible, adequately sized and equipped with suitable water outlets;

· After use, all disposable syringes, needles, lancets and other sharp instruments shall immediately be disposed of in specific hardcase, broad aperture containers employed exclusively for this type of laboratory wastes;

· All wastes generated in the examination room shall be collected and disposed of in specific containers for contaminated materials;

· Prior to beginning each autopsy, a 1:10 solution of sodium hypochlorite shall be specifically prepared and placed in a readily accessible position. The solution shall be used to disinfect potentially contaminated objects and surfaces during the performance of the autopsy. Residual solution shall not be stored and shall be suitably disposed of;

· Upon termination of each autopsy session, all work and floor surfaces and all contaminated surfaces shall be disinfected using a sodium hypochlorite solution and adequately rinsed;

· After use, all surgical instruments shall be soaked in a disinfectant solution. Soaking times shall be set according to the product manufacturer’s specific operating instructions. Subsequently instruments shall be washed manually using brushes and detergents. Instruments shall be dried using disposable towels employed solely for this task;

· All electric powered implements (saws, etc.) that require soaking in disinfectant solution for decontamination shall be equipped with appropriate electrical insulation;

· Upon completion of the autopsy, all operators shall wash their hands and remove their protective clothing prior to leaving the examination room;

· Protective clothing and linen items shall be placed directly in appropriate (polythene) soiled item containers for decontamination and washing.

Operators at all professional qualification levels, involved in this work phase (morgue activities), have been issued with the following specific instructions with respect to the procedures to be implemented in cases involving biologic agent exposure hazard (defined as “accident involving contamination hazard”):

· Due care shall be exercised in preventing accidental cuts or lacerations caused by potentially contaminated instruments and/or exposed and jagged bone extremities, spillage of blood and/or organic fluids;

· An operator that suffers cuts, pricks, soiling or whose skin or mucous tissue is splashed shall immediately interrupt his/her autopsy-related activities;

· Any lesion including needle pricks shall be allowed to bleed freely and shall be subsequently washed, disinfected and medicated. Any accidental contamination of mucous tissue (eyes and oral cavity) shall be immediately washed liberally using running water;

· All accidents (lesions, splashes, soiling) shall immediately be reported to supervisors;

· Operators accidentally exposed to blood or other biologic materials (accident involving contamination hazard) shall be subjected to initial tests (e.g. vaccination control, passive immunization, hepatitis B and C markers) and HIV follow-up. Furthermore, pursuant to current regulations, a proposal for chemoprofilaxis using antiretroviral drugs shall be lodged.

A Hepatitis B, Tetanus and Tuberculosis profilaxis vaccination campaign has been implemented.

With respect to formalin use, instructions have been issued for the elimination of dilution and transfer operations (to be performed only by qualified personnel using exhaust hoods) and use of suitably prepared tissue storage containers. Instructions have also been issued relating to the replacement of formalin with less toxic products.

Requirements have been put in place relating to the collection of wastes originating from processes involving contact with corpse materials (materials and disposable PPEs). Such materials shall not be considered as standard urban waste but as special waste products and shall be disposed of in appropriate “special wastes containers”. Such containers shall be stored in suitable, ventilated rooms. Room floors and walls shall be lined with waterproof, readily washable materials.

During the execution of the study, recommendations have been made relating to the need for further actions in job task organization, making specific reference to the number of operators required to perform corpse retrieval operations. Instruction/training programmes relating to load lifting methods are essential but have not as yet been implemented.

Chapter 6 - "Outsourcing"

Operations involving corpse retrieval and transfer to the morgue for autopsy are performed solely by morgue staff employed by the Municipality of Milan.

Cleaning and decontamination of morgue premises has been subjected to an outsourcing agreement.

Autopsy activities are performed by operators employed by the University and, currently, by ASL (Azienda Sanitaria Locale-local Ministry of Health agency). Previously some operators were employed by the Municipality.

Chapter 7 - "Legislative References"

The hereunder-listed legislative and bibliographic references relate to all the phases of the entire working cycle.

· D.P.R.n°547/1955 – Workplace Accident Prevention Rules

D.P.R.n°303/1956 – General Workplace Hygiene Rules
D.P.R.n°164/1956 – Construction site accident prevention Rules
D.Lgs.n°277/1991 – Implementation of Directives n°80/1107/EEC, n°82/605/EEC, n°83/477/EEC, n°86/188/EEC and n°88/642/EEC relating to protection of workers from chemical, physical and biologic exposure hazards pursuant to Article 7 of Law n°212, dated 30 July 1990

· D.Lgs.n°626/1994 and subsequent amendments – Implementation of Directives n°89/391/EEC, n°89/654/EEC, n°89/655/EEC, n°89/656/EEC, n°90/269/EEC, n°90/270/EEC, n°90/394/EEC and n°90/679/EEC relating to the enhancement of worker safety and health

· D.Lgs.n°475/1992 – Implementation of Council Directive 89/686/EEC dated 21/12/1989 relating to harmonization of member states’ legislation concerning personal protection equipment

· D.Lgs.n°494/1996 – Implementation of Directive n°92/57/EEC relating to minimum safety and health requirements for temporary or mobile construction sites

· Municipal building and health regulations

· D.P.R.n°285/1990 – Approval of Mortuary police Regulations

· Municipal Mortuary police Regulations

· Law n°292 dated 05/03/1963 (Mandatory anti-tetanus vaccination)

· D.M. 26/04/1990 and D.M. 04/10/1991 (Identification of risk groups for Hepatitis B virus vaccination)

· D.P.R.n°203/1988 – Implementation of Directives n°80/779/EEC, n°82/884/EEC, n°84/360/EEC and 85/203/EEC concerning air quality regulations relating to specific pollution and polluting agents produced by manufacturing facilities pursuant to Article 15, Law n°183 dated 16/04/1987