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COVID-19:Guidelines on dead body management: Govt. of India
COVID-19: Safe management of a dead body in the context of COVID-19 :WHO

COVID-19:Guidelines on dead body management: Govt. of India

1. Scope of the document

• There are currently over 100 laboratory confirmed cases and two deaths due to Novel Coronavirus disease (COVID-19) in India. Being a new disease there is knowledge gap on how to dispose of dead body of a suspect or confirmed case of COVID-19.
• This guideline is based on the current epidemiological knowledge about the COVID-19. India is currently having travel related cases and few cases of local transmission. At this stage, all suspect / confirmed cases will be isolated in a health care facility. Hence the document is limited in scope to hospital deaths.

2. Key Facts

• The main driver of transmission of COVID-19 is through droplets. There is unlikely to be an increased risk of COVID infection from a dead body to health workers or family members who follow standard precautions while handling body.
• Only the lungs of dead COVID patients, if handled during an autopsy, can be infectious.

3. Standard Precautions to be followed by health care workers while handling dead bodies of COVID.

Standard infection prevention control practices should be followed at all times.
These include:

1. Hand hygiene.
2. Use of personal protective equipment (e.g., water resistant apron, gloves, masks, eyewear).
3. Safe handling of sharps.
4. Disinfect bag housing dead body; instruments and devices used on the patient.
5. Disinfect linen. Clean and disinfect environmental surfaces.

4. Training in infection and prevention control practices

All staff identified to handle dead bodies in the isolation area, mortuary, ambulance and those workers in the crematorium / burial ground should be trained in the infection prevention control practices.

5. Removal of the body from the isolation room or area

• The health worker attending to the dead body should perform hand hygiene, ensure proper use of PPE (water resistant apron, goggles, N95 mask, gloves).
• All tubes, drains and catheters on the dead body should be removed.
• Any puncture holes or wounds (resulting from removal of catheter, drains, tubes, or otherwise) should be disinfected with 1% hypochlorite and dressed with impermeable material.
• Apply caution while handling sharps such as intravenous catheters and other sharp devices. They should be disposed into a sharps container.
• Plug Oral, nasal orifices of the dead body to prevent leakage of body fluids.
• If the family of the patient wishes to view the body at the time of removal from the isolation room or area, they may be allowed to do so with the application of Standard Precautions.
• Place the dead body in leak-proof plastic body bag. The exterior of the body bag can be decontaminated with 1% hypochlorite.The body bagcan be wrapped with a mortuary sheet or sheet provided by the family members.
• The body will be either handed over to the relatives or taken to mortuary.
• All used/ soiled linen should be handled with standard precautions, put in bio-hazard bag and the outer surface of the bag disinfected with hypochlorite solution.
• Used equipment should be autoclaved or decontaminated with disinfectant solutions in accordance with established infection prevention control practices.
• All medical waste must be handled and disposed of in accordance with Bio-medical waste management rules.
• The health staff who handled the body will remove personal protective equipment and will perform hand hygiene.
• Provide counseling to the family members and respect their sentiments.

6. Environmental cleaning and disinfection

All surfaces of the isolation area (floors, bed, railings, side tables, IV stand, etc.) should be wiped with 1% Sodium Hypochlorite solution; allow a contact time of 30 minutes, and then allowed to air dry.

7. Handling of dead body in Mortuary

• Mortuary staff handling COVID dead body should observe standard precautions.
• Dead bodies should be stored in cold chambers maintained at approximately 4°C.
• The mortuary must be kept clean. Environmental surfaces, instruments and transport trolleys should be properly disinfected with 1% Hypochlorite solution.
• After removing the body, the chamber door, handles and floor should be cleaned with sodium hypochlorite 1% solution.

8. Embalming

• • Embalming of dead body should not be allowed.

9. Autopsies on COVID-19 dead bodies

Autopsies should be avoided. If autopsy is to be performed for special reasons, the following infection prevention control practices should be adopted:

• The Team should be well trained in infection prevention control practices.
• The number of forensic experts and support staff in the autopsy room should be limited.
• The Team should use full complement of PPE (coveralls, head cover, shoe cover, N 95 mask, goggles / face shield).
• Round ended scissors should be used
• PM40 or any other heavy duty blades with blunted points to be used to reduce prick injuries
• Only one body cavity at a time should be dissected
• Unfixed organs must be held firm on the table and sliced with a sponge – care should be taken to protect the hand
• Negative pressure to be maintained in mortuary. An oscillator saw with suction extraction of the bone aerosol into a removable chamber should be used for sawing skull, otherwise a hand saw with a chain-mail glove may be used
• Needles should not be re-sheathed after fluid sampling – needles and syringes should be placed in a sharps bucket.
• Reduce aerosol generation during autopsy using appropriate techniques especially while handling lung tissue.
• After the procedure, body should be disinfected with 1% Sodium Hypochlorite and placed in a body bag, the exterior of which will again be decontaminated with 1% Sodium Hypochlorite solution.
• The body thereafter can be handed over to the relatives.
• Autopsy table to be disinfected as per standard protocol.

10. Transportation

• The body, secured in a body bag, exterior of which is decontaminated poses no additional risk to the staff transporting the dead body.
• The personnel handling the body may follow standard precautions (surgical mask, gloves).
• The vehicle, after the transfer of the body to cremation/ burial staff, will be decontaminated with 1% Sodium Hypochlorite.

11. At the crematorium/ Burial Ground

• The Crematorium/ burial Ground staff should be sensitized that COVID 19 does not pose additional risk.
• The staff will practice standard precautions of hand hygiene, use of masks and gloves.
• Viewing of the dead body by unzipping the face end of the body bag (by the staff using standard precautions) may be allowed, for the relatives to see the body for one last time.
• Religious rituals such as reading from religious scripts, sprinkling holy water and any other last rites that does not require touching of the body can be allowed.
• Bathing, kissing, hugging, etc. of the dead body should not be allowed.
• The funeral/ burial staff and family members should perform hand hygiene after cremation/ burial.
• The ash does not pose any risk and can be collected to perform the last rites.
• Large gathering at the crematorium/ burial ground should be avoided as a social distancing measure as it is possible that close family contacts may be symptomatic and/ or shedding the virus.

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Government of India
Ministry of Health & Family Welfare
Directorate General of Health Services
(EMR Division)
COVID-19: GUIDELINES ON DEAD BODY MANAGEMENT
15.03.2020

COVID-19: Safe management of a dead body in the context of COVID-19 :WHO

Preparing and packing the body for transfer from a patient room to an autopsy unit, mortuary, crematorium, or burial site

• Ensure that personnel who interact with the body (health care or mortuary staff, or the burial team) apply standard precautions,2,3 including hand hygiene before and after interaction with the body, and the environment; and use appropriate PPE according to the level of interaction with the body, including a gown and gloves. If there is a risk of splashes from the body fluids or secretions, personnel should use facial protection, including the use of face shield or goggles and medical mask;
• Prepare the body for transfer including removal of all lines, catheters and other tubes;
• Ensure that any body fluids leaking from orifices are contained;
• Keep both the movement and handling of the body to a minimum;
• Wrap body in cloth and transfer it as soon as possible to the mortuary area;
  – There is no need to disinfect the body before transfer to the mortuary area;
  – Body bags are not necessary, although they may be used for other reasons (e.g. excessive body fluid leakage); and
• No special transport equipment or vehicle is required.

Funeral home/ mortuary care

• Health care workers or mortuary staff preparing the body (e.g. washing the body, tidying hair, trimming nails, or shaving) should wear appropriate PPE according to standard precautions (gloves, impermeable disposable gown [or disposable gown with impermeable apron], medical mask, eye protection);
• If the family wishes only to view the body and not touch it, they may do so, using standard precautions at all times including hand hygiene. Give the family clear instructions not to touch or kiss the body;
• Embalming is not recommended to avoid excessive manipulation of the body;
• Adults >60 years and immunosuppressed persons should not directly interact with the body.

Autopsy, including engineering and environmental controls

• Safety procedures for deceased persons infected with COVID-19 should be consistent with those used for any autopsies of people who have died from an acute respiratory illness. If a person died during the infectious period of COVID-19, the lungs and other organs may still contain live virus, and additional respiratory protection is needed during aerosol-generating procedures (e.g. procedures that generate small-particle aerosols, such as the use of power saws or washing of intestines);
• If a body with suspected or confirmed COVID-19 is selected for autopsy, health care facilities must ensure that safety measures are in place to protect those performing the autopsy;4
• Perform autopsies in an adequately ventilated room, i.e. at least natural ventilation with at least 160L/s/patient air flow or negative pressure rooms with at least 12 air changes per hour (ACH) and controlled direction of air flow when using mechanical ventilation;5
• Only a minimum number of staff should be involved in the autopsy;
• Appropriate PPE must be available, including a scrub suit, long sleeved fluid-resistant gown, gloves (either two pairs or one pair autopsy gloves), and face shield (preferably) or goggles, and boots. A particulate respirator (N95 mask or FFP2 or FFP3 or its equivalent) should be used in the case of aerosol-generating procedures.6

Environmental cleaning and control

Human coronaviruses can remain infectious on surfaces for up to 9 days.7 COVID-19 virus has been detected after up to 72 hours in experimental conditions.8 Therefore, cleaning the environment is paramount.

• The mortuary must be kept clean and properly ventilated at all times;
• Lighting must be adequate. Surfaces and instruments should be made of materials that can be easily disinfected and maintained between autopsies;
• Instruments used during the autopsy should be cleaned and disinfected immediately after the autopsy, as part of the routine procedure;
• Environmental surfaces, where the body was prepared, should first be cleaned with soap and water, or a commercially prepared detergent solution;
• After cleaning, a disinfectant with a minimum concentration of 0.1% (1000 ppm) sodium hypochlorite (bleach), or 70% ethanol should be placed on a surface for at least 1 minute.9 Hospital-grade disinfectants may also be used as long as they have a label claim against emerging viruses and they remain on the surface according to manufacturer’s recommendations;
• Personnel should use appropriate PPE, including respiratory and eye protection, when preparing and using the disinfecting solutions; and
• Items classified as clinical waste must be handled and disposed of properly according to legal requirements.

Burial

People who have died from COVID-19 can be buried or cremated.

• Confirm national and local requirements that may dictate the handling and disposition of the remains.
• Family and friends may view the body after it has been prepared for burial, in accordance with customs. They should not touch or kiss the body and should wash hands thoroughly with soap and water after the viewing;
• Those tasked with placing the body in the grave, on the funeral pyre, etc., should wear gloves and wash hands with soap and water after removal of the gloves once the burial is complete.
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Burial by family members or for deaths at home

In contexts where mortuary services are not standard or reliably available, or where it is usual for ill people to die at home, families and traditional burial attendants can be equipped and educated to bury people under supervision.

• Any person (e.g. family member, religious leader) preparing the deceased (e.g. washing, cleaning or dressing body, tidying hair, trimming nails or shaving) in a community setting should wear gloves for any contact with the body. For any activity that may involve splashing of bodily fluids, eye and mouth protection (face shield or goggles and medical mask) should be worn. Clothing worn to prepare the body should be immediately removed and washed after the procedure, or an apron or gown should be worn;
• The person preparing the body should not kiss the deceased. Anyone who has assisted in preparing the body should thoroughly wash their hands with soap and water when finished;
• Apply principles of cultural sensitivity and ensure that family members reduce their exposure as much as possible. Children, older people (>60 years old), and anyone with underlying illnesses (such as respiratory illness, heart disease, diabetes, or compromised immune systems) should not be involved in preparing the body. A minimum number of people should be involved in preparations. Others may observe without touching the body at a minimum distance of 1 m;
• Family and friends may view the body after it has been prepared for burial, in accordance with customs. They should not touch or kiss the body and should wash their hands thoroughly with soap and water following the viewing; physical distancing measures should be strictly applied (at least 1 m between people).
• People with respiratory symptoms should not participate in the viewing or at least wear a medical mask to prevent contamination of the place and further transmission of the disease to others;
• Those tasked with placing the body in the grave, on the funeral pyre, etc. should wear gloves and wash hands with soap and water once the burial is complete;
• Cleaning of reusable PPE should be conducted in accordance with manufacturer’s instructions for all cleaning and disinfection products (e.g. concentration, application method and contact time, etc.);
• Children, adults > 60 years, and immunosuppressed persons should not directly interact with the body;
• Although burials should take place in a timely manner, in accordance with local practices, funeral ceremonies not involving the burial should be postponed, as much as possible, until the end of the epidemic. If a ceremony is held, the number of participants should be limited. Participants should observe physical distancing at all times, plus respiratory etiquette and hand hygiene;
• The belongings of the deceased person do not need to be burned or otherwise disposed of. However, they should be handled with gloves and cleaned with a detergent followed by disinfection with a solution of at least 70% ethanol or 0.1% (1000 ppm) bleach, and
• Clothing and other fabric belonging to the deceased should be machine washed with warm water at 60−90°C (140−194°F) and laundry detergent. If machine washing is not possible, linens can be soaked in hot water and soap in a large drum using a stick to stir and being careful to avoid splashing. The drum should then be emptied, and the linens soaked in 0.05% chlorine for approximately 30 minutes. Finally, the laundry should be rinsed with clean water and the linens allowed to dry fully in sunlight.10

WHO reference number: WHO/2019-nCoV/lPC_DBMgmt/2020.1