How to avoid infection after a COVID-19 death – an Ebola response veteran explains
As the grim reality of COVID-19 unfolds, families and health care workers in the United States are faced with dealing with the horrifying magnitude of deaths from this novel disease. This tragic situation brings forth the question of whether the bodies of patients who have died from COVID-19 provide a risk of infection in others.
I have worked for many years as an infectious disease doctor and public health official, during emerging disease outbreaks, such as Ebola virus disease in 2015. I have witnessed the extra challenges families experience when faced with the death of their loved ones from a highly transmissible infectious disease. For this current pandemic, here are the safety guidelines for dealing with deceased loved ones and the reasons why, from a scientific perspective.
Contagion risk decreases after death
The recommendations for handling those deceased from COVID-19 are based on knowledge that this novel coronavirus (SARS-CoV-2) is most commonly transmitted by respiratory droplets that are projected by a living person through coughing and sneezing. Therefore, after death, the risk from this respiratory mechanism is no longer present. However, the novel coronavirus (SARS-CoV-2) can also be transmitted from indirect contact: that is, touching a surface contaminated with the virus and then self-contaminating by touching one's eyes, nose or mouth.
Preventing transmission when handling the deceased is achieved by "contact precautions," which includes wearing a gown and gloves and hand-washing after removing these barriers. The deceased is placed in a body bag and the bag is then wiped down with EPA-approved disinfecting wipes prior to transportation.
This guidance holds in the funeral home setting as well, except there are additional instructions for preventing airborne transmission of coronavirus when certain body processing procedures, such as embalming, are performed.
This type of guidance in the health care setting is fairly standard for handling the deceased who is potentially infectious, given the risk of indirect contact of the patient with surrounding medical equipment, bedding and furniture.
During the Ebola pandemic, much stricter guidance was enforced, but this was also related to the tremendous amount of infectious fluids that were produced by a symptomatic patient, including profuse diarrhea. These precautions also took into consideration the extremely high mortality rate from Ebola.
At that time in 2015, I was working as a public health professional, and was involved in the determination of the best procedures to prevent cross-contamination when transferring a deceased patient with Ebola to the hospital morgue or elsewhere. A team of doctors, nurses and public health practitioners developed a protocol in a biocontainment unit with a patient mannequin and special chemical markers that could reveal contamination of surfaces via ultraviolet light.
This team was able to determine that multiple body bags were needed to prevent external contamination of the body bags being used. A careful manipulation of the patient, the bedding, proper personal protective equipment for staff and two stretchers was needed to achieve this level of caution.
Post-mortem safety for families
For families, there are many sad realities that need to be considered in the event of a death from COVID-19. While currently families are not allowed in the hospital to visit their loved ones, deaths in the home of those suspected of COVID-19 infection have been reported.
Again, given that breathing has stopped, the risk of transmission from coughing, sneezing and other mouth secretions is no longer a concern, but contact with surfaces that the patient could have previously contaminated remains. It is known that the virus can stay viable on surfaces for days, so all nearby surfaces should be considered infectious. Family members should thoroughly clean surfaces and bedding, wearing gloves and a washable or disposable cover up, if available.
Regarding funerals, when it is deemed safe to have a small gathering, or if exposed family members have completed their 14 day quarantine period, there is guidance on safety in those situations. There is no known risk of being in the same room at a funeral or visitation service with the body of someone who has died from COVID-19.
The CDC recommends not touching, kissing or hugging the deceased, though acknowledges that touching a hand or clothing after the body has been prepared for viewing is lower risk if hand-washing can then immediately occur.
Those at higher risk of complications of COVID-19 should use extra precaution in this setting. If there are important religious or cultural practices, such as shrouding or washing of the body, funeral home staff and local cultural and religious leaders can be involved to optimize reducing the risk of exposure.
Processing of the deceased can be achieved by cremation or embalming, and burial is allowed. For people who have died outside of the United States or need transportation for funeral services, federal and state guidelines need to be followed. For international transport, bodies can be transported if cremated, if embalmed and placed in a hermetically sealed casket or if the remains are accompanied by a CDC permit. This permit must be issued by the CDC director and allows for the importation of a person known or suspected of death from a quarantinable communicable disease.
How families can prepare
Know your risk of complications from COVID-19.
Know the warning signs of COVID-19 complications needing emergency medical care.
Understand your hospital policy on visitation of someone sick with COVID-19.
Learn the infection control and visitation policy in your family member's nursing home or assisted living facility.
Discuss end-of-life decisions with loved ones: living will, advanced directives, funeral and life ceremony wishes.
Know the CDC recommendations for handling the deceased in the home and in funeral homes.