2  Management of the dead associated to COVID-19, Technical Recommendations for Healthcare and Death Care workers
This part provides guidance on the measures required for effectively assisting in the management of the large numbers of dead from COVID-19 that may likely need an increase of the necessary human and material resources, including for building local capacity and supporting and/or carrying out the recovery and identification processes.

2.1  Important considerations of COVID-19
SARS-CoV-2, the virus which causes COVID-19, is classified as a HG3 (hazard group 3) pathogen (such as HIV and TB). In some infected people it may cause a severe and acute respiratory syndrome which can be fatal. There is presently still no vaccine or effective cure for COVID-19 infection and treatment is symptomatic.
The virus is known to spread mainly person-to-person:• Through respiratory droplets and fomites [4] produced when an infected person coughs or sneezes, between people who are in close contact with one another (within about 2 m or 6 feet). Infective aerosol and droplets may also be produced from splashes of contaminated fluids.
• Infection is also possible from contact with contaminated surfaces or objects by touching a surface or object that has the virus on it (e.g. fomites) and then touching own mucosa of mouth, nose, or eyes. The virus is known to normally survive a few hours outside the host, but this may extend to days in some conditions [6].
Working in environments overcrowded with people infected with COVID-19 is a risk factor (e.g. collecting the dead from an overcrowded detention facility), for which the personal protective equipment (PPE) recommended in this guidance provides adequate protection, if properly used.
The virus is easily neutralized with water and soap and with standard disinfectants, such as bleach and ethanol solutions [6].
Any post-mortem activities, from recovery, transport, to autopsies and handover to families and burial, should be therefore conducted with a focus on avoiding aerosol generating procedures, such as splashes of contaminated fluids; and ensuring that if aerosol generation is likely (e.g. when using an oscillating saw, which is NOT recommended) that appropriate engineering controls and PPE are used and that the disinfection of contaminated surfaces and equipment, together with thorough personal hygiene, especially hand-washing, are rigorously observed. These precautions and the use of standard precautions such as those recommended in this guidance should ensure that appropriate work practices are used to prevent direct contact with infectious material, percutaneous injury, and hazards related to moving heavy remains and handling embalming chemicals.

2.2  General principles for the management of human remains infected with COVID-19
• Any activity undertaken in relation to the management of known or suspected COVID-19 fatalities must be preceded by a preliminary evaluation and risk assessment (see section 3.1).
• Staff undertaking recovery and identification of human remains infected or suspected to be infected with COVID-19 must be specifically trained for the task of managing the dead and the use of PPE. The operation should be supervised by suitably qualified staff, at the minimum a forensic professional trained and experienced in the management of the dead in challenging circumstances.
• The procedures adopted must seek to limit the potential for staff exposure to COVID-19, prevent as far as is possible the spread of COVID-19 resulting from the process, allow for the timely and accurate recovery and identification of the human remains and ensure the dignity of the dead throughout the process.
• The management of large numbers of dead bodies requires that all necessary measures be adopted to ensure their documentation and traceability throughout, from recovery to storage and final disposal, to avoid their loss or misplacement and/or of the corresponding information. Special procedures should be put in place for the management and protection of the data on the dead.
• Where potential conflict arises between existing cultural practices and additional safeguards to prevent further exposure and propagation of the virus, the latter must take precedent and efforts should be made for ensuring that this is understood, accepted and supported by the concerned community or religious authorities and the next of kin.

2.3  Technical recommendations for body handlers
"Body handler" refers to any individual involved in the physical handling of human remains. This includes, but is not limited to, healthcare practitioners and healthcare assistant personnel, death care workers including forensic doctors, pathologists and other forensic experts, autopsy technicians, non-forensic personnel charged with recovery and transportation of human remains, individuals involved in body preparation for body disposal, for funerals or other commemorative events. Body handlers should take precautions when handling the remains of individuals that have died from COVID-19.• Use of standard PPE – Gloves (Ensure that gloves are unpunctured, nitrile gloves preferred)/aprons/long sleeved gowns/overalls to protect skin and clothing from contamination by infected material/Face masks and eye protection: Googles or face shields/Full-face masks: FFP3 masks or N95 respirators are currently considered best for preventing inhalation of aerosols and in case of splashes during the body handling process to protect the face, eyes, nose, and mouth (Table 1 ).
Table 1 Transmission based precautions (TBPs): Personal protective equipment (PPE) for care of deceased during COVID-19 pandemic. Table adapted from guidance developed by Department of Health and Social Care, Public Health Wales, Public Health Agency (PHA) Northern Ireland, Health Protection Scotland and Public Health England [7].
Low risk Procedures∗:Admission of deceasedPreparation for viewingRelease of deceased Medium risk Procedures∗∗:Rolling deceasedUndressing deceasedSignificant manual handling High risk Procedures:Autopsy and other invasive procedures
Disposable gloves Yes Yes Yes
Disposable plastic apron Yes Yes Yes
Disposable gown No No Yes
Fluid-resistant (Type IIR) surgical mask (FRSM) Yes No No
Filtering face piece (FFP)∗∗∗ No FFP2 or FFP3 FFP3
Disposable eye protection Yes Yes Yes
Protective footwear (e.g. rubber boots which can be disinfected after use) Yes Yes Yes
∗If procedure likely to cause droplet contact, use medium risk procedure.
∗∗If procedure likely to generate aerosols, use high risk procedure. ∗∗∗ECDC (European Centre for Disease Prevention and Control) recommends the use of FFP3 masks for performing aerosol-generating procedures [15]. In case of shortage of Class 3 respirators, the use of Class 2 respirators (e.g. FFP2) may be considered, on a case by case basis and after assessing the risks of the procedures required.
• Shoe protection is desirable, ideally consisting of rubber boots which can be disinfected after use.
• If there is a risk of cuts, puncture wounds, or other injuries that break the skin, wear heavy-duty gloves over the nitrile gloves.
• Where possible use double body bags or body bags for infectious cases if available.
• Disinfect any non-disposable equipment being used during the handling of the remains as per standard practice.
• Used PPE should be properly disposed of to avoid contact with people, food, drink, or eating and drinking utensils. Biohazardous waste incineration is best.
• Avoid contact with your face and mouth, as well as food, drink, or eating and drinking utensils, during body handling.
• Rigorously wash hands after body handling and prior to eating or drinking.
• Do not engage in any other activity during the body handling or preparation process.
• Following the body handling or preparation process, rigorously wash hands and disinfect surfaces that may have come in contact with the infected body.
• Be aware of any hazards, in addition to COVID-19, which may be present in the environment and site of the location of the body.
• Ensure that any potentially contaminated staff clothing is not taken to their place of residence or those of others before proper cleaning.
• The potential for COVID-19 in human remains continues to pose a cross contamination hazard for some time after they have been removed from the site of recovery (hours and possibly days [6]).
• Similarly, personal effects of the deceased may also continue to pose a cross contamination hazard. If they are to be returned to next of kin, careful consideration must be given to an appropriate means of decontamination to ensure that the health of those receiving these items is not endangered.
• Similarly, documentation created during the recovery, transport, examination, storage and burial process may become infected with COVID-19 and should be disinfected accordingly.
• The process of recovering and identification of human remains of COVID-19 fatalities will generate waste products which are also potentially infected with COVID-19. Careful consideration must be given to safe management and disposal of this waste to ensure that the safety of those involved is not compromised and the spread of COVID-19 is avoided.
• Transport the body to the mortuary (or disinfection location if no post-mortem examination will occur) as soon as possible.

2.4  Considerations for post-mortem examinations
Deaths known to be caused by COVID-19 are natural deaths and in general would not require a full-post mortem examination. However, this may be required in certain circumstances (e.g. deaths in custody [8]) or when other factors are suspected (e.g. accident, suicide, homicide) regardless of the COVID-19 status of the deceased person. The decision for carrying out a full or partial post-mortem examination is normally the responsibility of the jurisdictional authority in charge (e.g. coroner, prosecutor, judge), sometimes after discussions with the investigators and forensic medical doctors. If there is no need for autopsy in COVID-19 suspected cases, sampling technique used to confirm the cause of death is identical to the one used for making diagnosing of COVID-19 suspected cases for patients [20,21].
For conducting autopsies, in addition to the above the following PPE is recommended: double surgical gloves interposed with a layer of cut-proof synthetic mesh gloves, fluid-resistant or impermeable gown, waterproof apron, goggles or face shield and FFP3 masks or NIOSH-certified disposable N-95 respirator or higher. For further guidance, see the briefing issued by The Royal College of Pathologists [[9], [24]], as well as that from a consortium of Italian forensic pathologists [22]. When possible, appropriate designed rooms with proper ventilation should be used for the examination, to minimize the risk for transmission of airborne pathogens as much as possible [19].

2.5  Special considerations in case of non-identified bodies
Where required the forensic procedures recommended by the ICRC for the identification of the dead are applicable to the identification of those infected with COVID-19 [[16], [17], [18]], with certain caveats as follows:• Remains infected with COVID-19 with persistent agent may pose a cross contamination hazard to unprotected people hence visual recognition by next of kin should be strictly controlled and follow the necessary precautions, including the wearing of PPE. Furthermore, due to the likely complexity of the recovery operation and the greater time taken, remains may have decomposed beyond the point where visual recognition is of any value by the time they are recovered.
• All those involved in the examination and identification process of human remains known or believed to be infected with COVID-19 are required to wear appropriate PPE. This PPE has an impact on the wearer’s dexterity and their ability to perform fine motor skills. In addition, the performance of invasive techniques may increase the risk to staff of cross contamination. For these reasons, the use of invasive techniques should be avoided wherever possible.
• The extra safeguards required for the handling of infected remains potentially increases the time required to perform the identification and post mortem process as well as the physiological burden on the staff undertaking them.
• Where it is decided to conduct identification (and post mortem examination), this should also be conducted within the temporary holding area. This will help avoid overwhelming and contaminating normal mortuary facilities and endangering their staff, which will be expected to run business as usual.

2.6  Special considerations for temporary holding areas
The purpose of the temporary holding area is to serve as a place where recovered bodies and human remains infected with COVID-19 can be safely stored until arrangements can be made for their disposal.
Where recovered bodies and human remains continue to pose a risk of cross contamination, staff working in the temporary holding area (including those involved in the identification and post mortem process) must wear appropriate PPE always. Attention must be paid to contamination control within the temporary holding area. Dependent on the type and persistency of agent to which the remains have been exposed, it may be necessary to undertake some or all the following steps:• Disinfection of body bags upon arrival at the temporary holding area
• Placing of original body bag containing the remains inside of a second bag
• Disinfection of the outer bag following the identification or post mortem procedure
• Wearing of two layers of gloves (the outer pair being nitrile gloves) by all personnel when handling body bags or remains to reduce cross contamination
• If the case has been tested positive to COVID 19, the body bag should be clearly and permanently labelled, such as: “COVID-19 – Handle with care”
• Records should be kept of all movements of human remains within the temporary holding area and strict adherence to health and safety protocols should be ensured at all times. There must also be a continuous means of communication between the temporary holding area and the team coordinating the overall process.

2.7  Special considerations for final disposal of remains/hand over to relatives
• Decisions on the final disposal of bodies and human remains infected with COVID-19 will vary according to local, cultural and religious context, for which there may be a need to consult with relevant stakeholders, particularly religious representatives, to ensure that changes to standard practice are acceptable. Transparent conversation with such societal leaders is likely to be essential to sustain trust between authorities and the community.
• If final disposal is to take place off-site, human remains should be placed in a second outer body bag. (If the human remains have already been double-bagged, the outer bag should be removed and replaced with a new outer bag). This outer bag should be thoroughly disinfected prior to release from the site.
• Cremation of unidentified human remains should be avoided, and burial in single graves is the preferred method of disposal [5], but care must be taken to ensure that run-off from the decomposing human remains is managed so as not to contaminate ground water. Bodies should be buried in their respective body bags, regardless of the use of coffins. This will help in their future recovery and examination if necessary (e.g. identification) as well as taking care of the disposal of the body bags.
• Personal belongings of the deceased infected with COVID-19 may present a cross contamination hazard. Consideration should be given to decontamination of such possessions prior to handing them over to the next of kin to avoid the spread of contamination and associated risks to health. Where it is not possible to decontaminate possessions, careful consideration must be given as to whether it is appropriate to hand such possessions to the next of kin or whether they should be stored for later safe release. If a decision is made to dispose of such objects as contaminated waste, they should be duly documented, together with a justification for this procedure.

2.8  Considerations for decontamination procedures
• Decontamination procedures can be divided into those for the staff undertaking the management of the dead procedures (along with their equipment) and decontamination of the human remains. The objectives are to ensure the health and safety of those carrying out the handling of the dead and to prevent the unnecessary spread of contamination.
• The decontamination approach should be considered as part of the planning process with a view to ensuring the most effective method is adopted, including processes for management of waste generated during the process.
• The most suitable approach is to place human remains into two body bags at the site of recovery and manage the contamination on the outside of the bag by a combination of contamination monitoring and washing of the outside of the bag.
• Decontamination of the body is not advisable, mainly because bodies may release inhaled vapor from the respiratory system or other internal contamination via other routes after initial decontamination and vigorous decontamination of bodies or body parts may destroy forensic evidence or obscure identifying marks which may make identification more difficult.
• The exact method chosen (if any) for decontamination of the body bags should follow the standard procedures for COVID-19 and the use of recommended disinfectants.
• Decontamination of staff will be as per the method defined for the PPE worn.
• Upon completion of the process, prior to removal of any equipment from the temporary holding area, care must be taken to ensure that it does not present a cross contamination hazard. This will involve monitoring each piece of equipment for contamination and decontamination of equipment as is deemed necessary.
• Any equipment which cannot be disinfected from COVID-19 must be disposed of as infected waste, following standard biosecurity procedures. This usually requires their controlled storage, transport and incineration.