Handling of Cadavers in a Mortuary amidst COVID-19 Pandemic

Introduction

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2), a member of the betacoronavirus family.^1,2 It was first identified in December 2019 in Wuhan and since then had spread globally. World Health Organization (WHO) declared it a pandemic on March 11, 2020.^2,3 As it is caused by a novel coronavirus, the exact pathophysiology of the disease, its course, and therapeutics are not fully understood, as of now. As a result it has led to considerable anxiety and panic not only in general public but also among the health care workers.⁴ However, from a living person, the virus spreads between people during close contact (i.e., within approximately 6 feet), often via small droplets produced by coughing, sneezing, and talking. This route of infection is not a concern when handling human remains or performing postmortem procedures. People may also become infected by touching a contaminated surface and then touching their face.^5-7 The asymptomatic carriers of the virus tend not to get tested and contribute significantly to the spread of disease.^8,9 The standard method of diagnosis is by real time reverse transcriptase polymerase chain reaction from a nasopharyngeal (NP) swab. Recommended measures to prevent infection include frequent hand washing, maintain physical distance from others especially from those with symptoms, quarantine, covering coughs, and keeping unwashed hands away from face.^10,11 Till date, there are no available vaccine nor specified antiviral treatment for COVID-19.⁵ This new disease is a challenge for the whole medical community including paramedics, and they are at significant risk of getting infection if standard infection prevention and control measures are not taken.

According to WHO, dead bodies are generally not infectious except in cases of hemorrhagic fevers (Ebola, Marburg) and cholera. Only the lungs of the patients with pandemic influenza, if handled improperly during autopsy can be infectious. WHO further adds that any body fluids leaking from orifices in the cadavers must be contained. There is no need to disinfect the body before transfer to the mortuary area.¹²

The first incidence of COVID-19 being transmitted from a dead body to a medical professional in a Forensic Medicine unit occurred in Thailand on April 14, 2020.¹³ However, in India, no such case has been reported till date.

Although not much is known about how long the novel coronavirus can live in dead bodies, yet “anyone coming in contact with a COVID-19 positive body alive or dead should be using personal protective equipment (PPE) to prevent exposure” Health policy expert Summer Johnson McGee of the University of New Haven told BuzzFeed News by e-mail. Coroners are increasingly being asked to conduct investigations into the cause of death for patients who had died and were not tested. She further added that autopsies and the subsequent investigations pose real risks for coroners to get infected by COVID-19.¹⁴

The infectious disease specialist and assistant professor at the University of Alberta, Dr. Schwartz said, “It would be possible that the virus could persist and remain infectious in or on the body of someone who has died.”¹⁵

Guidelines on Dead Body Management in the Mortuary

Government of India, Ministry of Health and Family Welfare (MoHFW) Director General of Health Services (EMR Division) has issued guidelines on dead body management on March 15, 2020 based on the current epidemiological knowledge about COVID-19. According to the guidelines, all the staff identified to handle dead bodies in the mortuary should be trained in the infection prevention control practices and observe following standard precautions.^16,17

1. Hand hygiene is the first and foremost preventive measure to be followed before and after the interaction with the dead body.

2. Use of PPE (e.g., water-resistant apron, gloves, masks, and eyewear).

3. Safe handling of sharps.

4. Used equipments should be autoclaved or decontaminated with disinfectant solutions in accordance with established infection prevention control measures.

5. All soiled/used linen should be handled with standard precautions, put in the bio-hazard bag and the outer surface of the bag disinfected with hypochlorite solution.

6. All medical waste must be disposed of in accordance with biomedical waste management rules.

7. All the surfaces of mortuary like floor, mortuary table, door handles should be wiped with 1% sodium hypochlorite solution, allow a contact time of 30 minutes, then allow to dry.

8. Dead bodies should be stored in cold chambers maintained at approximately 4°C.

9. Embalming of dead body should not be allowed to avoid excessive manipulation of the body.

10. Adults more than 60 years of age and immunosuppressed persons should not directly interact with the body.

Precautions Taken during Autopsy Procedure

Standard precautions, contact precautions, and airborne precautions with eye protection (goggles or a face shield) should be followed during autopsy. These are consistent with the existing guidelines for safe work practices in the autopsy setting.^17,18

Recommended Biosafety and Infection Control Practices during Specimen Collection

Following are the CDC, Government of India guidelines regarding collection and submission of postmortem specimen from diseased (persons with known or suspected COVID-19).¹⁸ NP swab is the preferred choice for upper respiratory tract swab-based SARS-CoV-2 testing. Collection of NP swab specimens from a dead person will not induce coughing or sneezing, a negative pressure room is not required, however, standard precautions should be observed. Biosafety cabinet for handling and examining smaller specimens should be used.

The following PPE should be worn at a minimum:

• Wear nonsterile nitrile gloves.

• If there is risk of cut or puncture wounds, wear heavy duty gloves over the nitrile gloves.

• Wear long sleeved impermeable gown.

• Used plastic face shield/goggles.

Biomedical Waste Management and Environmental Cleaning

• After the procedure, discard the PPE in the appropriate laundry or waste receptacle. Reusable PPE like face shield or googles, must be disinfected. Wash hands with soap and water for 20 seconds. Avoid touching face.^17,18

• The body of the deceased 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.

• Autopsy table to be disinfected as per standard protocol.

• Keep ventilation system active while cleaning is conducted.

• Do not use water under pressure for cleaning as it may re-aerosolize infectious material.

• Dispose off human tissues according to routine procedures.

Disinfect/Autoclave Instruments

The body thereafter can be handed over to the relatives.