Infection Prevention and Control for the safe management of a dead body in the context of COVID-19 Interim guidance 24 March 2020 Background Preparing and packing the body for transfer This interim guidance is for all those, including managers of from a patient room to an autopsy unit, health care facilities and mortuaries, religious and public mortuary, crematorium, or burial site health authorities, and families, who tend to the bodies of persons who have died of suspected or confirmed COVID-19. • Ensure that personnel who interact with the body (health care or mortuary staff, or the burial team) These recommendations are subject to revision as new apply standard precautions,2,3 including hand evidence becomes available. Please refer to the WHO website hygiene before and after interaction with the body, for updates on the virus and technical guidance. 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 Key considerations splashes from the body fluids or secretions, personnel should use facial protection, including • COVID-19 is an acute respiratory illness caused by the use of face shield or goggles and medical mask; COVID-19 virus that predominantly affects the • Prepare the body for transfer including removal of lungs; all lines, catheters and other tubes; • Based on current evidence, the COVID-19 virus is • Ensure that any body fluids leaking from orifices are transmitted between people through droplets, contained; fomites and close contact, with possible spread • Keep both the movement and handling of the body through faeces. It is not airborne. As this is a new to a minimum; virus whose source and disease progression are not • Wrap body in cloth and transfer it as soon as possible yet entirely clear, more precautions may be used to the mortuary area; until further information becomes available; There is no need to disinfect the body before • Except in cases of hemorrhagic fevers (such as – transfer to the mortuary area; Ebola, Marburg) and cholera, dead bodies are – Body bags are not necessary, although they may generally not infectious. Only the lungs of patients be used for other reasons (e.g. excessive body with pandemic influenza, if handled improperly fluid leakage); and during an autopsy, can be infectious. Otherwise, • No special transport equipment or vehicle is cadavers do not transmit disease. It is a common required. myth that persons who have died of a communicable disease should be cremated, but this is not true. Cremation is a matter of cultural choice and available resources;1 Funeral home/ mortuary care • To date there is no evidence of persons having • Health care workers or mortuary staff preparing the become infected from exposure to the bodies of body (e.g. washing the body, tidying hair, trimming persons who died from COVID-19; nails, or shaving) should wear appropriate PPE • People may die of COVID-19 in the health care according to standard precautions (gloves, facilities, home or in other locations; impermeable disposable gown [or disposable gown • The safety and well-being of everyone who tends to with impermeable apron], medical mask, eye bodies should be the first priority. Before attending protection); to a body, people should ensure that the necessary • If the family wishes only to view the body and not hand hygiene and personal protective equipment touch it, they may do so, using standard precautions (PPE) supplies are available (see Annex I); at all times including hand hygiene. Give the family • The dignity of the dead, their cultural and religious clear instructions not to touch or kiss the body; traditions, and their families should be respected and • Embalming is not recommended to avoid excessive protected throughout; manipulation of the body; • Hasty disposal of a dead from COVID-19 should be • Adults >60 years and immunosuppressed persons avoided; should not directly interact with the body. • Authorities should manage each situation on a case-by-case basis, balancing the rights of the family, the need to investigate the cause of death, and the risks of exposure to infection. -1- Infection Prevention and Control for dead body management in the context of COVID-19: Interim guidance Autopsy, including engineering and placed on a surface for at least 1 minute.7 Hospital-grade disinfectants may also be used as environmental controls long as they have a label claim against emerging • Safety procedures for deceased persons infected viruses and they remain on the surface according to manufacturer’s recommendations; with COVID-19 should be consistent with those • Personnel should use appropriate PPE, including used for any autopsies of people who have died from respiratory and eye protection, when preparing and an acute respiratory illness. If a person died during using the disinfecting solutions; and the infectious period of COVID-19, the lungs and • Items classified as clinical waste must be handled other organs may still contain live virus, and and disposed of properly according to legal additional respiratory protection is needed during requirements. aerosol-generating procedures (e.g. procedures that generate small-particle aerosols, such as the use of Burial power saws or washing of intestines); • If a body with suspected or confirmed COVID-19 is People who have died from COVID-19 can be buried or cremated. selected for autopsy, health care facilities must ensure that safety measures are in place to protect • Confirm national and local requirements that may those performing the autopsy;4 dictate the handling and disposition of the remains. • • Perform autopsies in an adequately ventilated room, Family and friends may view the body after it has been prepared for burial, in accordance with customs. i.e. at least natural ventilation with at least They should not touch or kiss the body and should 160L/s/patient air flow or negative pressure rooms wash hands thoroughly with soap and water after the with at least 12 air changes per hour (ACH) and viewing; controlled direction of air flow when using • Those tasked with placing the body in the grave, on mechanical ventilation;5 the funeral pyre, etc., should wear gloves and wash • Only a minimum number of staff should be involved hands with soap and water after removal of the gloves once the burial is complete. in the autopsy; • Appropriate PPE must be available, including a scrub suit, long sleeved fluid-resistant gown, gloves Burial by family members or for deaths at home (either two pairs or one pair autopsy gloves), and face shield (preferably) or goggles, and boots. A In contexts where mortuary services are not standard or particulate respirator (N95 mask or FFP2 or FFP3 or reliably available, or where it is usual for ill people to die at home, families and traditional burial attendants can be its equivalent) should be used in the case of equipped and educated to bury people under supervision. aerosol-generating procedures.6 • Any person (e.g. family member, religious leader) preparing the deceased (e.g. washing, cleaning or dressing body, tidying hair, trimming nails or Environmental cleaning and control shaving) in a community setting should wear gloves for any contact with the body. For any activity that Human coronaviruses can remain infectious on surfaces for may involve splashing of bodily fluids, eye and up to 9 days.7 COVID-19 virus has been detected after up to mouth protection (face shield or goggles and 72 hours in experimental conditions.8 Therefore, cleaning the medical mask) should be worn. Clothing worn to environment is paramount. prepare the body should be immediately removed • The mortuary must be kept clean and properly and washed after the procedure, or an apron or gown ventilated at all times; should be worn; • Lighting must be adequate. Surfaces and • The person preparing the body should not kiss the instruments should be made of materials that can be deceased. Anyone who has assisted in preparing the easily disinfected and maintained between body should thoroughly wash their hands with soap autopsies; and water when finished; • Instruments used during the autopsy should be • Apply principles of cultural sensitivity and ensure cleaned and disinfected immediately after the that family members reduce their exposure as much autopsy, as part of the routine procedure; as possible. Children, older people (>60 years old), • Environmental surfaces, where the body was and anyone with underlying illnesses (such as prepared, should first be cleaned with soap and respiratory illness, heart disease, diabetes, or water, or a commercially prepared detergent compromised immune systems) should not be solution; involved in preparing the body. A minimum • After cleaning, a disinfectant with a minimum number of people should be involved in concentration of 0.1% (1000 ppm) sodium preparations. Others may observe without touching hypochlorite (bleach), or 70% ethanol should be the body at a minimum distance of 1 m; -2- Infection Prevention and Control for dead body management in the context of COVID-19: Interim guidance • Family and friends may view the body after it has https://www.who.int/publications-detail/standard- been prepared for burial, in accordance with customs. precautions-in-health-care (accessed They should not touch or kiss the body and should March 22, 2020). wash their hands thoroughly with soap and water 3. World Health Organization. (2020). Infection following the viewing; physical distancing measures prevention and control during health care when should be strictly applied (at least 1 m between COVID-19 is suspected: interim guidance, people). 25 January 2020. • People with respiratory symptoms should not https://www.who.int/publications-detail/infection- participate in the viewing or at least wear a medical prevention-and-control-during-health-care-when- mask to prevent contamination of the place and novel-coronavirus-(ncov)-infection-is-suspected- further transmission of the disease to others; 20200125.