Recommendations by Expert Group on disposal of corpses of persons infected with SARS-CoV-2 Virus

 The expert committee has revised the recommendations on disposal of bodies to include both cremation and burial, while adhering to the specified safety precautions

Following is the full report of recommendations by the Expert Group on disposal of corpses of persons infected with SARS-CoV-2 Virus

Introduction

Cremation has been considered as the safest mode of disposal of SARS-CoV-2 infected dead bodies in the country since it was a new virus with limited scientific data about its potential modes of sustainable human-to-human transmission with associated risks to the community in the initial phase of the outbreak and also in the context of a very limited prevalence within the country. 

During the past one year, knowledge on the SARS-CoV-2 virus infection and its transmission has increased significantly. As such, the Ministry of Health Requested the expert committee comprising microbiologist, virologists and immunologists to revisit the previous guideline1 on disposal of corpses of persons infected with SARS-CoV-2 virus. 

Key points and scientific evidence considered in drafting the report 

The virus and its transmission 

COVID-19 is an acute respiratory disease caused by SARS-CoV-2 that mainly affects the lungs and respiratory tract2.

a) The SARS CoV-2 virus is an enveloped virus and is destroyed more rapidly by adverse environmental conditions when compared to a non-enveloped virus. 

b) It is transmitted to other persons by living, infected persons when they excrete droplets through respiratory secretions during breathing, coughing, sneezing, speaking and related activities. 

c)The virus can also be detected on surfaces and objects handled by infected persons and may be present for varying periods of time and may get transmitted to others through their contaminated hands3. 

d) The virus has been isolated in urine and faeces of some of the infected persons and is potentially infectious4. 

e) The virus has been detected in low numbers in plasma and serum of some patients suggesting that they are potentially infectious4.

f) The viruses cannot replicate in the body once an infected person dies and the remaining virus in the body dies over a period of time with the death of a person as there are no more living cells. 

g) SARS-CoV-2 virus infection is not a water-borne disease. Contamination of water by residual virus in a corpse leaking in the water table through layers of soil to reach levels of the infectious dose is very remote as any residual infection virus continues to die. Furthermore, any residual infectious virus that reached the water table gets diluted in the large volume of water. Therefore, the amount of virus in the water is insufficient to lead to infection either by ingestion, contact with mucus membranes, or through contaminated hands as the minimal infectious dose of the virus is quite high. For the same reason, there also has been no evidence of transmission through water contamination from burial by SARS or influenza. However, water contamination could be avoided to a large extent by wrapping the body using virus impervious material such as use of non-biodegradable body bags. 

h) The dead body of a person infected with SAR-CoV-2 virus is potentially infectious and disposal has to be carried out ensuring safety of all those who come into close contact with the body.

While firmly standing by on the previous recommendation and guidelines on exclusive cremations of dead bodies as the most appropriate method of disposal which was based on the understanding at the time, the expert committee has revised the recommendations on disposal of bodies to include both cremation and burial, while adhering to the specified safety precautions.

Recommendations for disposal of a body from health facility/mortuary to the crematorium/burial site and participation of family members and religious dignitaries

a) The dignity of the dead and their families should be respected and protected as far as possible throughout the process used for the disposal of the body2.

b) Designated healthcare personnel should only do the handling of the corpses.

c) The body should not be handed over to the relatives for cremation or burial. 

d) Ensure all those who interact with the body (the healthcare and mortuary staff) apply standard infection prevention and control (IPC) precautions. Continuous and adequate hand hygiene supplies, PPE, cleaning and disinfection supplies should be made available2. 

e) The bodies for cremation or burial should not be embalmed2. 

f) The cremation or burial should be carried out within 24 hours, once the order for disposal of the body is given. 

g) The body should be laid inside a double layered body bag, prior to placing in the coffin. The body bags should be of 300 um thickness, padded with absorbent material, leak proof and non-biodegradable5. 

h) Viewing of the body will be permitted only within the healthcare facility/mortuary.

i) If the family wishes to view the body, open/unzip the body bag and allow them to view the body at a one-meter distance wearing a mask and keeping a distance of one meter from each other. Touching the body or the belongings of the dead person is not permitted. The body should not be removed from the body bag for viewing2.

j) Only four persons from the family will be allowed to view the body. Two persons at a time should be allowed to view the body and a maximum period of five min/per two persons should be allowed for viewing the body under supervision. A total period of 10 min is allowed for viewing the body. 

k) When the body is transported to a crematorium/burial site by health authorities, a maximum of four persons from the family could be permitted to accompany the body in a separate mode of transport. 

l) The crematorium/burial site designated by the healthcare authorities should be used for disposal of the body.

m) The coffin shall not be opened for any reason at the crematorium or the burial site. 

n) Allow 10 minutes for any religious activity under supervision at the crematorium/burial site prior to cremating/burying while observing social distancing and standard precautions. Only one religious dignitary and four persons from the family will be permitted to be present during the religious activity.

o) The bottom of the grave should be 1.5 m from the ground surface and 1.2 m above the water table. The distance between burial site and field drains should be 10 m minimum. The distance between burial site and drinking wells, boreholes, and wells should be 250 m minimum. The distance between burial site and springs and water courses should be 30 m minimum as per current recommendations by global experts6. 

Signed,

Professor Jennifer Perera, Senior Professor in Microbiology (Chairperson) 

Professor Neelika Malavige, Professor in Microbiology (Member)

Dr. Geethani Galagoda, Consultant Virologist (Member)

Dr. Rajeeva de Silva, Consultant Immunologist (Member)

Dr. Kanthi Nanayakkara, Consultant Virologist (Member)

Dr. Malika Karunaratne, Consultant Microbiologist (Member)

Dr. Rohitha Muthugala, Consultant Virologist (Member)

Dr. Nadeeka Janage, Consultant Virologist (Member)

Dr. Saranga Sumathipala, Consultant Virologist (Member)

Dr. Dulmini Kumarasinghe, Consultant Virologist (Member)

Dr. Janaki Abeynayake, Consultant Virologist (Member)

References 

1 Extraordinary Gazette notification (No. 2170/8), Minister of Health and Indigenous Medical Services under Section 2 and 3 of the Quarantine and Prevention of Diseases Ordinance (Chapter 222), Government of Sri Lanka (2020). http://documents.gov.lk/files/egz/2020/4/2170-08_E.pdf 

2 Infection prevention and control for the safe management of a dead body in the context of COVID-19: interim guidance, Geneva: World Health Organization; 4th September 2020

3 Carraturo F, Del Giudice C, Morelli M, Cerullo V, Libralato G, Galdiero E, Guida M. Environ Pollut. 2020 Oct; 265: 115010. Published online 2020 Jun 9. Doi: 10.1016/j.envpol.2020.115010

4 Transmission of SARS-CoV-2: implications for infection prevention precautions: Scientific brief. World Health Organization; July 2020.

5 International Federation of Red Cross and Red Crescent Societies, Standard Products Catalogue. http://itemscatalogue.redcross.int/index.aspx 

6 Oran Finegan, Denise Abboud, Stephen Fonseca, Igor Malgrati, Maria Dolores, M Morcillo Medex, Jean-Marc Burri, Pierre Guyomarc’h’ International Committee of the Red Cross (ICRC): Cemetery planning, preparation and management during COVID-19: A quick guide to proper documentation and despositon of the dead. Forensic Science International 316 (2020) 110436.