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Medico-Legal Journal
2020, Vol. 88(2) 80–83
Dead body management amidst global ! The Author(s) 2020
Article reuse guidelines:

pandemic of Covid-19 sagepub.com/journals-permissions

DOI: 10.1177/0025817220926930
journals.sagepub.com/home/mlj

Raghvendra Kumar Vidua1, Irena Duskova2, Daideepya C Bhargava1,

Vivek Kumar Chouksey1 and Parthasarathi Pramanik3

Abstract
Covid-19 has reached almost all the nations in the world. More and more people are dying from it and in some
countries, even the army has been called upon to help dispose of the dead as there is a shortage of coffins, and
undertakers are overwhelmed. Therefore, it is essential to have measures in place to contain the spread of infection
while handling dead bodies. In view of this, different guidelines and protocols have been proposed bearing in mind the
limited information we have about the virus. This review article sets them out for better reference.

Keywords
Pandemic, Covid-19, dead body management, personal protective equipment, disinfectant, sodium hypochlorite

1
AIIMS Bhopal, Bhopal, India
Introduction 2
Second Faculty of Medicine, Charles University, Bulovka Hospital,
Prague, Czech Republic
Covid-19 is an acute respiratory illness caused by the 3
Institute of Forensic Science and Legal Medicine, Government of
virus affecting the respiratory system and particularly Jamaica, Kingston, Jamaica
the lungs. The source and disease progression of this
Corresponding author:
virus are not yet entirely clear. The research is going on Raghvendra Kumar Vidua, Department of Forensic Medicine &
to find out the exact information. However, as per the Toxicology, AIIMS Bhopal, MP, India-462020.
information available with us, except in cases of viral Email: raghvendra.fmt@aiimsbhopal.edu.in
Vidua et al.
haemorrhagic infections, pandemic influenza and chol-
era, the dead bodies are generally not infectious.
Meanwhile, for better safety while handling a dead
body in such a case, people should ensure necessary
hand hygiene and wearing of personal protective equip-
ment (PPE) for minimising any chance of such infec-
tion. Even in this panicky situation, the dignity of the
dead should be protected throughout. The authorities
involved should manage each situation on a case-by-
case basis, balancing the rights of the family, the need
to find out the cause of death and the risks of expo-
sure.1 In a country like China, if foreigners die of coro-
navirus infection, the body is cremated on the spot and
the cremated ashes can be transported out of the
country.
Covid-19 and mortality
SARS-CoV-2 virus is the causative agent and belongs
to the family of Coronaviridae and is an enveloped,
positive-sense single-stranded RNA virus.1 The SARS
(Severe Acute Respiratory Syndrome)-related and
MERS (Middle East Respiratory Syndrome)-related
corona viruses are both considered HG3 pathogens,2
while most others are HG2.7. The World Health
Organization (WHO) has linked the association of
the present outbreak with the Huanan South China
Seafood Marketplace.1 The main route of transmission
is considered to take place through large respiratory
droplets by inhalation or deposits on mucosal surfaces,
but contact with contaminated bodily excretions, air-
borne and faeco-oral routes have also been proposed.3
The average incubation period is 5 to 6 days (range 0–
14 days).1 The environmental stability of the virus
varies from 3 h post-aerosolisation to 2–3 days on plas-
tic and stainless steel.3 On the basis of available data,
the mortality rate was calculated as 5.6% (95% confi-
dence interval 5.4–5.8) for China and 15.2% (12.5–
17.9) outside China4 and as high as 20% in Wuhan.5
So far, most studies have focused on the epidemiol-
ogy and potential causes but studies exploring preven-
tion and control measures have begun to gradually
increase and are urgently needed to minimise the
impact of the outbreak.6 Several public health meas-
ures like isolation, identification, follow-up of contacts,
environmental disinfection and use of PPE have been
introduced.7
Even after many countries announced a lockdown
to contain the spread of this viral pandemic, the man-
agement of infected dead bodies and funerals remain a
source of concern at the time of writing in countries
where the daily death tolls are very high. The Ministry
of Health and Family Welfare in India issued a detailed
guidance for the handling of infected dead bodies. It
recommends leak-proof plastic body bags with a
81
thickness of not less than 150 mm to be used with
another layer of a mortuary sheet or opaque bag and
decontamination of the exterior of the body bag.
Further, no embalming is allowed.8 The Indian
Council for Medical Research considers the preferred
method for disposal to be cremation by electric or
CNG (Compressed natural gas)-run crematoria.
There is no evidence so far of transmission of virus
through the handling of corpses3 but the virus may also
persist on them and unnecessary contact with bodies
and exposure to infected bodily fluids should be mini-
mised by wearing PPE. Conversely, aerosol-generating
procedures during autopsy require eye protection and
facial filter piece respirators.
WHO recommendations
Manipulation of the body should be minimal and the
remains should not be sprayed, washed or embalmed.
A high standard of personal hygiene should be adopted
along with the use of PPE. All staff should be trained in
the prevention of infections to avoid direct contact with
body or body fluids. Hand hygiene could be achieved
by washing hands with liquid soap and water or proper
use of alcohol-based hand rub. WHO recommends
wearing a full set of PPE together with heavy-duty
rubber gloves and, in cases of accidental exposure,
washing of the exposed area with copious amount of
water.1
Step-wise approach
1. Isolation ward: Ensure that personnel who handle
the body apply standard precautions, including
strict hand hygiene and appropriate PPE. Prepare
the body for transfer including removal of all lines,
catheters and other tubes and ensure that any body
fluids leaking from orifices are contained and keep
movement and handling of the body to a minimum.
2. Proper packing before transfer: Wrap the body in
cloth and transfer it as soon as possible to the mor-
tuary area. Using leak-proof body bags may avoid
excessive body fluid leakage. The isolation room
should be properly disinfected after the transfer.
3. Transfer of body to the mortuary: It is preferable to
transport corpses in a cleanable, fluid retentive (e.g.
fibreglass), temporary coffin.9 After every transfer
the vehicle or stretcher should be disinfected with
chlorine-containing disinfectant.
4. In cold storage: The designated compartments of
cold storage facility should be used and disinfected
after removal of the body. If possible, discontinue
the cold chain in them when not in use.
5. Shifting and preparation for autopsy: Mortuary staff
preparing the body should wear appropriate PPE.
82
6. Autopsy: In a confirmed case of Covid-19 death
autopsy should be avoided; however, it may be
conducted in a medico-legal case. The lungs and
other organs may still contain live virus, so addi-
tional respiratory protection is needed during
aerosol-generating procedures (e.g. use of power
saws or washing of intestines). If cause of death
has been found, then opening lungs and other
organs should be avoided as much as possible.
The autopsy should be performed in an adequately
ventilated room with at least 160 L/s/patient air
flow or a negative pressure room with at least 12
air changes per hour. The staff involved in the
autopsy should be reduced to the minimum and
wear appropriate PPE including a scrub suit,
long-sleeved fluid-resistant gown, gloves and face
shield or goggles, boots and a particulate respirator
(N95 mask or its equivalent).
An oscillator saw with suction extraction into a
removable chamber or simply a hammer and chisel
should be used for sawing the skull. The Royal
College of Pathologists has recommended a staged
postmortem in such cases.10 In widespread infections,
a minimally invasive autopsy can be performed.11
Standard surgical masks are not suitable and valved
fold flat and moulded protection masks are appropri-
ate.12 The larger airways (segmental and primary
bronchi) have been found to contain a higher yield
of virus and postmortem computed tomography scan-
ning can be used for pulmonary findings.13
7. Packing of body: After autopsy, all organs should
be retained inside the body and all cavities and
body orifices should be plugged. Wound drainage
and needle puncture holes should be disinfected
and dressed with impermeable material.14 The
body should be wrapped in cloth and kept inside
an impermeable body bag. If the risk of leakage of
fluid is high, then double body bagging should be
done and their surfaces wiped with a suitable
disinfectant.15
8. Handing over the body: When the body is handed
over to the police and relatives after autopsy, then
they must be advised not to open the bags or touch
the body and not to gather together to minimise
spreading infection.
9. At home: If the family wishes just to view the body
and not touch it, they may do so, using standard
precautions at all times.
10. At funeral site: At a funeral home, the body handlers
(e.g. those tasked with placing the body in the grave,
on the funeral pyre, etc.) should wear appropriate
PPE. The body should be cremated as soon as pos-
sible with post-funeral hand hygiene of handlers and
sanitising the specified area. The ash can be collected
Medico-Legal Journal 88(2)
to perform the last rites. There should be no large
gathering at the crematorium or burial ground.
11. Environmental cleaning and control: The virus can
remain infectious on surfaces for up to nine days3
and can be detected for up to 72 h in experimental
conditions.1 Therefore, keeping the environment
clean is very important. All HVAC (Heating
Ventilation and Air Conditioning) system should
be shut down and windows be kept open.
Environmental surfaces and instruments should
be disinfected between procedures.15
12. Deaths at home: Families and traditional burial
attendants can be equipped and educated to bury
people under supervision. Family members must
reduce their exposure as much as possible. The
belongings of the deceased should be handled
with gloves and cleaned with a detergent and
chlorine-based disinfectant. Clothing and other
fabric should be machine washed in detergent
with warm water and allowed to dry in sunlight.
13. Waste management: All medical waste must be han-
dled and disposed of in accordance with biomedical
waste management rules. Double-layer packaging
bags and gooseneck-type seals should be used in
layers. There should be warning signs on the
outer surfaces and high-risk wastes should be pres-
sure steam sterilised or chemically sterilised at the
place of production itself. After the daily delivery,
clean and disinfect the delivery tools.16
Considerations to reduce the risk of
transmission
1. General requirements: People-oriented, speedy, sci-
entific and safe cremation with safety measures in
place at every step.
2. Administrative measures: Establish a preparedness
and information management plan with division of
responsibilities and ensure adequately trained staff,
transportation, equipment as readily available.
3. Review national civil contingency plans: to deal with a
sudden surge in numbers.
4. Identify key professional groups within and outside
the healthcare system: that will be handling of dead
bodies. Ensure the PPE is supplied and being used
by them.
5. Transparent conversation with social and religious
leaders: to ensure that changes to standard practice
are acceptable.
6. Preparation at site of death: This may be performed
using appropriate standard precautions and PPE.
7. Environmental cleaning and waste management at site
of death site: Regular cleaning followed by
Vidua et al.
disinfection with 0.1% sodium hypochlorite is
recommended.15
8. If a surface is likely to be damaged by sodium hypo-
chlorite: an alternative is to use a neutral detergent,
followed by a 70% concentration of ethanol. Waste
should be treated as infectious clinical waste
Category B (UN3291).17 The cleaning and waste
management staff should wear appropriate PPE.1
9. Considerations for community deaths: The authorities
that will manage dead bodies in the community
should have access to PPE.
Conclusion
It is evident that Covid-19 is a highly contagious viral
infection and people who have to deal with infected
dead bodies are at risk and must take due precautions
at each stage of disposal.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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