COVID-19 end life care- management of dead body

There is minimal risk of spread of COVID-19 infection from a dead body if standard precautionary measures are followed. However, misconceptions, stigma, and discrimination of the families remain when a person dies of COVID-19. Therefore, the following guideline is an updated and expanded version of the guidelines, which also includes additional sections on handling COVID-19 deaths in a home/community setting, safety guideline for the caregiver of the deceased, and prevention of stigmatization and discrimination during COVID-19 deaths.

Preparation of the body in a healthcare institution setting:

1. Personnel who handle the body should follow all standard Infection Prevention and Control (IPC) precautions of the hospital.
2. Appropriate PPE should be used depending on the level of contact with the body. Usually face shield or goggles, medical mask, gown, and gloves are recommended.
3. Remove tubes, drains, catheters, etc from the body. Take care while handling sharp articles like IV cannula which should be disposed as per biomedical waste disposal norms.
4. Leakage of body fluids from body orifices or wound openings like tracheotomy should be contained. This may be achieved by packing with cotton or gauze dipped in disinfectant like 1% sodium hypochloride solution.
5. Minimize moving or handling the body while preparing the body.
6. Embalming should not be done to avoid excessive manipulation of the body. If absolutely necessary, it should be done by trained, experienced staff following standard IPC precautions.
7. If the family wishes to see the body at the time of removing from the isolation room or area, they will be allowed to do so without touching or kissing the body and following COVID-19 appropriate behaviors like maintaining physical distancing from one another, wearing mask, and perform hand hygiene after viewing. Strictly they should not come into contact with the healthcare personnel handling the body.
8. Wrap the body in a leak-proof plastic body bag or leak-proof plastic sheet, after which the exterior should be disinfected with 1% sodium hypochlorite solution.
9. Place the wrapped body into a coffin and seal it. Place the coffin on a stretcher and disinfect the coffin with 1% sodium hypochlorite solution and wait for 30 minutes. After transferring the body, the stretcher should be properly disinfected.
10. Environmental surfaces where the body was prepared should be cleaned with a disinfectant solution, or soap and water. After this, douse the surface with a disinfectant (a minimum concentration of 0.1% sodium hypochlorite/bleach or 70% ethanol) and let it sit for at least 1 minute.
11. Items which fall under the category of clinical waste should be disposed as per hospital biomedical waste management protocol.
12. All surfaces of the isolation area such as floors, beds, railings, side tables, IV stands, etc. should be wiped with 1% sodium hypochlorite solution and allow a contact time of 30 minutes and then allow to air dry. Used equipment should be autoclaved as per IPC practices.
13. The body from there may be taken to a mortuary or handed over to the family or Village Disaster Management Authority (VDMA) or taken to the burial site/crematorium, as the case may be according to District Task Force arrangement/protocol.

NB:     Autopsies should be avoided. If autopsy should be performed for special reasons, safety precautions should be consistent with those that apply to the autopsies of people who have died of an acute respiratory illness or other infectious diseases. Refer to section 9 ‘Autopsies on COVID-19 dead bodies’ under the ‘COVID-19: Guidelines on dead body management’ issued by Ministry of Health and Family Welfare, 15th March, 2020.

Transportation:

1. After the body is prepared, sealed in a coffin, and disinfected as mentioned above, there is no additional risk to the people involved in transporting the body.
2. Persons involved in handling the coffin should wear gloves and mask. Hand hygiene should be performed once the burial/cremation is complete.
3. There is no special vehicle required for transportation to the burial/cremation site. There should not be crowding in the vehicle during transportation.
4. The vehicle afterward should be disinfected with 1% sodium hypochlorite solution or formulated bleaching powder.

At the burial site/crematorium:

• People who have died of COVID-19 can be buried/cremated similar to other deaths as per local standards and family preferences.
• The coffin be sealed and the body should be buried or cremated with the coffin.
• The number of persons that can attend the funeral/burial/cremation shall be as per the prevailing government guideline. At the time of issue of this guideline, not more than 20 persons are allowed to attend a funeral.
• Funeral program should be held in open space with good ventilation and physical distancing should be maintained at all times.
• The persons responsible for placing the coffin in the grave or on the funeral pyre should wear gloves and mask, and perform hand hygiene afterwards.

Full PPE is not required at the burial site/crematorium as it can cause more stigma.

• The body thus buried does not pose any health or environmental hazard. The ash after cremation does not pose any health risk and can be collected for last rites.

Preparation of the body and burial/cremation in a home/community setting:

• In context where the institutional services are not applicable such as death in the home/community setting, traditional burial attendants or Village Disaster Management Authority volunteers can be instructed in the preparation of body for burial or cremation.

The guidelines on preparation of the body, wherever applicable, may be replicated from the healthcare institutional setting as mentioned above.

• Persons involved in preparing the body should not be elderly or persons with underlying health conditions.
• Any person preparing the body should wear gloves for any physical contact with the body. If there is any possibility of splashing bodily fluids or aerosols generation, face shield or goggles along with mask is recommended. Apron or a long sleeved fluid resistant gown should be worn during the procedure, or clothing worn should be immediately removed and washed.
• Minimal handling of the body should be aimed. If the body needs to be turned, cover the body with a sheet beforehand.
• Plastic or clothing sheet can be used to wrap the body or a body bag if available.
• Other family members should be strictly instructed not to touch the deceased.
• Family and friends in limited number can view the body after the preparation is complete. If a body bag is used, the head part may be kept unzipped temporarily using safety precautions by those handling the body. Physical distancing of 1 metre should be maintained among those who participate in the funeral proceedings.
• Persons involved in placing the body/coffin in the grave or funeral pyre should wear gloves and mask and perform hand hygiene after burial is complete.
• The belongings of the deceased should be handled with gloves and cleaned with detergent, following which a disinfectant should be applied like 70% ethanol solution, or 0.1% hypochlorite or bleach solution.
• Linens of the deceased can be soaked in hot water and soap/detergent in a large drum, using a stick to stir. Splashing should be avoided. Empty the drum and soak the linens in 0.05% hypochlorite/ bleach for about 30 minutes. Rinse with clean water and dry in sunlight.

Safety guidelines for caregivers/attendants of the deceased:

• The caregiver/attendant who had taken care of the deceased or family members who had direct contact while alive should follow medical protocol of testing and quarantine/ isolation.
• In a community/home setting, the caregiver/attendant should follow 10 days home quarantine from the date of the death and follow COVID appropriate behavior. If asymptomatic throughout, there is no requirement for test and he/she is released from quarantine henceforth.
• Persons involved in handling of the dead body, unless there was accidental exposure to body fluid or breach of PPE (e.g. torn gloves, mask not worn) need not go into quarantine. He/ She should maintain COVID-19 appropriate behavior of wearing mask, washing hands, and maintaining physical distancing, and report any COVID-like symptom immediately to health department or district task force.

Prevention of stigmatization/ discrimination during COVID-19 death:

• Village/ward authorities are prohibited from imposing additional restrictions on the place of burial or cremation of COVID-19 deaths if the safety precautions in this guideline are followed.
• Families, relatives and friends of the deceased shall be allowed to travel and attend the funeral based on the following conditions and exceptions:

• Persons from containment zone shall not be allowed to travel and attend funeral outside the containment zone.
• During lockdown or period of travel restrictions, the family members, relatives, and friends of the deceased may be allowed to travel to attend funeral on special permission from to the concerned district task force (origin and destination) with safety precautions. They should follow COVID-19 appropriate behavior and should not freely mingle with the community/local people. They shall view the funeral and travel back on the same day after the burial/cremation. If they are unable to travel back on the same day, home quarantine (for travellers) or isolation or testing protocol as applicable during the period should be followed.

• COVID-19 death should not be stigmatized and   families   affected   should   not   be discriminate. The dead should be honoured and families should be allowed to pay their last respect to the deceased in a safe manner.
• Appropriate action shall be taken against any person or entity going against the government directive as per Nagaland Epidemic Disease (COVID-19) Regulations 2020, National Disaster Management Act 2005, or relevant sections of Law.

Contact your nearest hospital for more information. All SOPs and guidelines issued from the Department will be available in www.nagahealth.nagaland.gov.in for more information on COVID-19 and other health issues dial State helpline no-1800-345-0019.