Main principles
Advice primarily designed to assist people who are required to manage the bodies of deceased persons infected with coronavirus (COVID-19).
This guidance has been developed to ensure that:
- the bodies of those people who have died as a result of coronavirus (COVID-19) and the bereaved family of the deceased are treated with sensitivity, dignity and respect
- people who work in these services and mourners are protected from infection
This guidance remains under review and may be updated in line with the changing situation as required.
What you need to know
Those handling bodies should be aware that there is likely to be a continuing risk of infection from the body fluids and tissues of cases where coronavirus (SARS-CoV2) infection is identified, through either a clinical diagnosis or laboratory confirmation.
The usual principles of Standard Infection Control Precautions (SICPs) and Transmission-Based Precautions (TBPs) apply for bodies that are suspected or confirmed to be infected with coronavirus (SARS-CoV2). No additional precautions are needed unless Aerosol Generating Procedures (AGPs) are being undertaken.
This guidance should be read in conjunction with:
The risk from people who have died from a SARS-CoV2 infection arises as a result of aerosols generated in the post-mortem handling of the deceased. Management of this hazard will substantially reduce the residual risk as the virus will rapidly degrade when not sustained by living tissue. As a result, there is no requirement for body bags, but there may be other practical reasons for their use.
Communities, organisations and individuals are strongly advised to take action to reduce the risk of spreading the infection among mourners who are gathered to pay their respects, with a particular focus on protecting vulnerable people. This includes:
- restricting the number of mourners who attend so that a safe distance of at least 2 metres (3 steps) can be maintained between individuals
- only the following should attend:
- members of the person’s household
- close family members
- if the deceased has neither household or family members in attendance, then it is possible for a modest number friends to attend
- mourners should also follow the advice on social distancing when travelling to and from the funeral gathering.
- individuals who have symptoms of coronavirus (COVID-19), or who are part of a household where someone has symptoms, or who are vulnerable to severe infection should not participate in rituals or religious gatherings
- mourners should not take part in rituals or practices that bring them into close contact with the body. Contact with the body should be restricted to those who are wearing PPE and have been trained in the appropriate use of PPE
Background
This guidance will assist professionals (coroners, mortuary operators, pathologists and other medical practitioners, funeral directors and their staff) who are required to manage bodies of deceased persons infected with coronavirus (SARS-CoV2).
There is additional information for:
- healthcare workers (secondary care and primary care) who come into contact with a body that may be infectious
- members of the public who identify a death in the community
- residential care settings including care homes and hospices
- first responders managing a death in the community
- communities managing a death
The guidance also includes specific information for faith communities and the public to help them take action to reduce the risk to mourners and the bereaved, following a death from any cause in the community.
Detailed information on coronavirus (COVID-19) and guidance for a range of settings is available. General information for the public is available.
Risk of transmission of COVID-19 from an infected body
Public Health England’s (PHE’s) Rare and Imported Pathogens Laboratory has assessed the post-mortem risk from people who have died of coronavirus (SARS-CoV2) infection and has identified little residual hazard apart from:
- potential droplet generation from artificial air movement during the initial care of the deceased
- post-mortem examination where the use of power tools take place, which is a risk for aerosol generation
It is estimated that viable virus could be present for up to 48 to 72 hours on environmental surfaces in “room air” conditions. In deceased bodies, particularly those retained at refrigeration conditions, and depending on the above factors, infectious virus may persist for longer and testing for suspected cases should be considered.
Due to the consolidation of respiratory secretions and rapid degradation of the virus when not sustained by live tissues, residual hazard from body fluid spillage will not present a risk. Therefore, body bags are not deemed necessary but may be used for other practical reasons. Placing a cloth or mask over the mouth of the deceased when moving them can help to prevent the release of aerosols.
The principles of SICPs and TBPs continue to apply while deceased individuals remain in the care environment.
This is due to the ongoing risk of infectious transmission via contact, although the risk is usually lower than for living patients. Where the deceased was known or suspected to have been infected with coronavirus (SARS-CoV2), there is no requirement for a body bag, and viewing, hygienic preparations, post-mortem and embalming are all permitted when undertaken by professionals trained in handling bodies of the deceased.
Following a risk assessment of the potential post-mortem risk pathways, PHE has developed this advice in line with the principles in the HSE guidance for droplet transmission risk, as set out in Managing infection risks when handling the deceased.
Guidance for professionals who manage bodies, including mortuary staff, pathologists and funeral directors
This section of the guidance is for professionals responsible for managing bodies.
The HSE guidance Managing infection risks when handling the deceased provides advice on the risks of infection from work activities involved with handling the deceased. It covers the safe handling, storage and examination of bodies in hospitals, mortuaries and post-mortem rooms. It also provides guidance for those involved in funeral services (including embalmers) and exhumations of human remains. Handling of deceased persons potentially infected with coronavirus (SARS-CoV2) should follow the SICPs and TBPs set out in the HSE guidance, apart from the use of body bags, which are not required but may be used for other practical reasons.
The Department of Health (2013) guidance Environment and sustainability. Health Technical Memorandum. 07-01: Safe management of healthcare waste in conjunction with the HSE guidance ‘Managing infection risks when handling the deceased’ provides details of the disposal of clinical waste.
Personal Protective Equipment (PPE)
RCPath in consultation with PHE has published guidance on the PPE requirements for care of the deceased during the coronavirus (COVID-19) pandemic. This table should be used by all professionals who manage deceased persons who are suspected or confirmed to be infected with coronavirus (SARS-CoV2).
Transmission-based precautions for coronavirus (COVID-19)
|
Non-autopsy procedures, including admission of deceased, booking-in of deceased, preparation for viewing, release of deceased |
Autopsy procedures, including other invasive procedures |
| Disposable gloves |
Yes |
Yes |
| Disposable plastic apron |
Yes |
Yes |
| Disposable gown |
No |
Yes |
| Fluid-resistant (Type IIR) surgical mask (FRSM) |
Yes |
No |
| Filtering face piece (class 3) (FFP3) respirator |
No |
Yes |
| Disposable eye protection |
Yes |
Yes |
Employees should ensure they are aware of their employer’s procedures regarding PPE and that they are using them correctly. Employees should remove any PPE and contaminated clothing when they leave a dirty work area. People should not enter clean areas wearing PPE.
Guidance on donning and doffing of PPE, including posters and videos, is available.
Appropriate use of PPE may protect clothes from contamination, but staff should change out of work clothes before travelling home. Work clothes should be washed separately, in accordance with the manufacturer’s instructions.
Instructions for processing of samples taken from bodies
If directed by a coroner or pathologist to obtain samples for coronavirus (SARS-CoV2) diagnostic testing in the deceased, the same process should be followed as for those in living patients. Detailed guidance on laboratory investigations and sample requirements for diagnosis is available and a poster detailing sampling and packing required is also available. If autopsy is performed, a lung biopsy can be sent in a sterile universal container without any additive. Ideally, the sample should be fresh frozen and sent on dry ice where possible. The sample should NOT be placed in formalin. RCPath has developed guidance on histopathology frozen sections and cytology fine needle aspiration during infectious disease outbreaks.
Management of cleaning and waste
Advice on cleaning and disinfection is available in the HSE guidance Managing infection risks when handling the deceased with specific reference to appendix 3.
Advice on waste disposal is available in the same guidance (see page 20).
Guidance for managing deaths in secondary care
Where there has been a death in secondary care, healthcare workers should refer to the infection prevention and control guidance for secondary care.
See guidance on donning and doffing of PPE.
Guidance for GPs managing a death outside of a healthcare setting
If you are a GP and a patient dies of suspected COVID-19 outside of a healthcare setting, follow the general guidance for primary care:
- advise others not to enter the room
- wear PPE in line with standard infection control precautions, such as gloves, apron and fluid resistant surgical mask
- keep exposure to a minimum
Guidance for members of the public who identify a death outside of a healthcare setting
If you are a member of the public or a family member and you come into contact with a deceased person who has been confirmed as having coronavirus (COVID-19), or who had symptoms of the infection, try not to come into direct contact with them. Move to at least 2 metres away or another room. Please call the GP (if the GP is not available you will be connected to out of hours) or 111 for further advice. If the death was unexpected and you have not been engaging with the healthcare system regarding the patient’s condition prior to the death, please call 999 and explain the situation.
Guidance on managing waste and laundry in the community setting is below.
Guidance for residential care settings including care homes and hospices
If a resident dies of suspected coronavirus (COVID-19) in a residential care setting:
- ensure that all residents maintain a distance of at least 2 metres (3 steps) or are in another room from the deceased person
- avoid all non-essential staff contact with the deceased person to minimise risk of exposure. If a member of staff does need to provide care for the deceased person, this should be kept to a minimum and correct PPE used as set out in the guidance on residential care provision (gloves, apron and fluid resistant surgical mask)
- you should follow the usual processes for dealing with a death in your setting, ensuring that infection prevention and control measures are implemented as set out in the guidance on residential care provision
Guidance for first responders managing a death in the community
See general advice for first responders, including the handling of the deceased
Specific advice for Ambulance trusts includes information about PPE requirements for aerosol generating procedures, such as intubation and suctioning.
Guidance for communities managing a death
There is an increased risk of transmission of coronavirus (COVID-19) where families and communities come together following the death of a loved one, from any cause. While recognising the importance of these rituals and gatherings, it is strongly advised that the actions detailed in the following sections are taken to reduce the spread of infection, particularly to vulnerable people who are at risk of developing a severe infection. See detailed information on social distancing and protecting older people and vulnerable groups. See additional information on the extremely vulnerable.
It is recognised that household members of the deceased person may have already been exposed to the virus during the course of the preceding illness. However, steps should be taken to minimise further exposure, and these should be rigorously applied in cases where individuals who are not part of the household and those at risk of severe illness would otherwise come into contact with the virus.
Those organising a funeral should adhere to the following:
- restrict the number of mourners who attend so that a safe distance of at least 2 metres (3 steps) can be maintained between individuals
- only the following should attend:
- members of the person’s household
- close family members
- if the deceased has neither household or family members in attendance, then it is possible for a modest number of friends to attend
- at no point should mourners mix closer than 2 metres apart from each other
- mourners should follow the advice on social distancing when travelling to and from the funeral gathering
- mourners should avoid any direct face-to-face or physical contact, for example, hugging each other unless they are part of the same household, that is, they have already been living in the same house as each other
- mourners in attendance, should follow the general advice on hand hygiene and preventing the spread of infection:
- wash your hands more often than usual, for 20 seconds using soap and hot water, particularly after coughing, sneezing and blowing your nose, or after being in public areas where other people are doing so. Use hand sanitiser if that’s all you have access to and wash your hands with soap and hot water as soon as you can
- to reduce the spread of germs when you cough or sneeze, cover your mouth and nose with a tissue, or your sleeve (not your hands) if you don’t have a tissue, and throw the tissue away immediately. Then wash your hands or use a hand sanitising gel
- before and after each service, clean and disinfect the area in which the service has taken place, as well as frequently touched objects and surfaces using your regular cleaning products to reduce the risk of passing the infection on to other people
- mourners who are unwell with symptoms of coronavirus (COVID-19), or are part of a household with possible coronavirus (COVID-19) infection, should not attend any gatherings
- in many situations the household members of the deceased person will be the next of kin; they may be having to self-isolate in line with household guidance. Where the funeral is scheduled to take place before the period of household isolation has been completed (14 days from the first case in that household), there should be no mixing between mourners who are self-isolating and those who are not
- mourners who are symptomatic should not attend in any circumstance
Practices that involve close contact with the body
There may be coronavirus (SARS-CoV2) on the body, which presents a small but real risk of transmission.
Viewing, hygienic preparations, post-mortem and embalming are all permitted by professionals experienced in handling bodies of deceased persons, if appropriate precautions are followed, as detailed in the HSE and RCPath guidance.
Cremation is permitted where the deceased does not have a medical device that requires removal. If the removal of a medical device requires AGPs, this will need to be agreed with the relevant professional who is managing the deceased.
Since there is a small but real risk of transmission from the body of the deceased, we strongly advise that mourners should not take part in any rituals or practices that bring them into close contact with the body of an individual who has died from, or with symptoms of, coronavirus (COVID-19) for the duration of the pandemic. Given the very significant risk for vulnerable and extremely vulnerable people who come into contact with the virus, it is strongly advised that they have no contact with the body. This includes washing, preparing or dressing the body.
It is recognised that household members may have come into contact with the virus over the course of the illness in the deceased person. However, even in these cases, we advise against further contact with the body without appropriate PPE as it may pose additional risk. The use of PPE in those circumstances should only be under the supervision of a professional trained in the appropriate use of PPE.
There is an increased risk of spreading coronavirus (COVID-19) infection among family members and communities who come together for gatherings, for example, for the purposes of mourning the deceased. Communities are strongly advised to take action to reduce the risk of transmission to the older people and vulnerable adults in their community when they are planning funerals or other gatherings to celebrate the passing of a loved one.
As above, in situations where the next of kin are household members who are likely to have already been exposed to the virus and may be self-isolating, all steps should be taken to minimise transmission to mourners outside the household and to mourners who are at increased risk of severe disease. This may require that mourners pay their respects in small groups, with those who are in self-isolation doing so after others who are well and not self-isolating. Mourners who are symptomatic should not attend in any circumstance. People who are vulnerable should adhere strictly to social distancing. People who are extremely vulnerable should not attend due to the increased risk of coronavirus (COVID-19) infection spreading among family members and communities who come together.
It is strongly advised that the following principles are followed:
- mourners who are unwell with the symptoms of coronavirus (COVID-19), or are part of a household with possible coronavirus (COVID-19) infection, should not participate as they may infect others and should be isolating at home as per the stay at home guidance
- individuals who are in a risk group should not attend gatherings and should practice social distancing, as they risk picking up an infection from other members of the community who may otherwise seem well
- you can find the list of vulnerable groups and the list of extremely vulnerable groups who should practice shielding
- plans should be put in place to allow mourners to participate remotely where possible with priority given to people who are vulnerable to severe infection
- the number of mourners should be restricted to minimise the risk of person spread and to allow a safer distance between individuals (at least 2 meters or 3 steps away from each other)
- mourners should minimise any direct face-to-face or physical contact, for example, hugging each other unless they are part of the same household, that is, they have already been living in the same house as each other
- mourners who attend should be signposted to the advice on social distancing and given information about what to do should they become unwell
Infection prevention and control
General infection control principles, applicable for handling the deceased in the community, are available at infection prevention and control.
Management of waste and laundry in the community setting
Personal waste (for example, used tissues, continence pads and other items soiled with bodily fluids) and disposable cleaning cloths can be stored securely within disposable rubbish bags, as set out in the guidance on cleaning in non-healthcare settings.
These bags should be placed into another bag, tied securely and kept separate from other waste. This should be put aside for at least 72 hours before being put in the usual household waste bin for disposal as normal.
Dirty laundry should not be shaken out to minimise the possibility of dispersing virus through the air.
Wash items as appropriate, in accordance with the manufacturer’s instructions.
If a washing machine is not available, the laundry can then be taken to a public laundromat 72 hours after last contact with the infected person.
Items heavily soiled with body fluids, for example, vomit or diarrhoea, or items that cannot be washed, should be disposed of, with the owner’s consent.