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Interim Guidance On Postmortem Care Of A Decedent Whose Death Is Confirmed Or Suspected To Be Attributed To COVID-19

January 11, 2021 

This interim guidance is being released to Coroners and Medical Examiners based on currently known information about COVID-19 as released by the Pennsylvania Department of Health (DOH) and the Centers for Disease Control and Prevention (CDC). For specific guidance from the CDC, please refer to their Collection and Submission of Postmortem Specimens from Deceased Persons with Known or Suspected COVID-19.  This interim guidance supersedes the interim guidance issued on April 7, 2020 and previously amended on June 29, 2020.

Handling of the Decedent's Body

COVID-19 is classified as an infectious disease. The virus that causes COVID-19 is primarily spread through respiratory droplets produced when an infected person coughs or sneezes. This type of spread is not a concern after death. Follow standard routine procedures for infection control measures when handling a decedent's body where the death is confirmed or suspected to be attributed to COVID-19. Coroners and medical examiners are encouraged to apply the "Criteria for COVID-19 Testing" on the next page to identify deaths suspected to be attributed to COVID-19.

The decedent's body should be removed from the premises based on standard timeframes. For deaths suspected to be attributed to COVID-19, it is highly recommended that specimen collection be done after the body is removed from the premises so as to not delay removal. The coroner or medical examiner should wear usual personal protective equipment (PPE) and practice physical distancing while in the setting, especially if family members/friends/onlookers are present. Because COVID-19 is spread in a similar manner to influenza, adhere to proper hand hygiene and other infection control measures. Gloves and hand washing are the most effective method to prevent this mode of transmission.

Because the spread of COVID-19 is not a concern after death, a NIOSH-certified disposable N-95 respirator or higher is not required.

Transportation of Decedent's Body

When transferring a body to a bag, follow Standard Precautions consistent with procedures used for death where COVID-19 is not suspected; include additional PPE if splashing of fluids is expected. Given the varying weights of decedents and the variety, construction, and conditions of body bag materials, postmortem care workers should use prudent judgement determining whether risks for puncture, tearing, or failure of body bags could occur and whether a second body bag or a body bag of thicker, stronger material (e.g., minimum of 6 mil thickness) is necessary. Risk factors include but are not limited to:

  • Presence of sharp objects on the decedent that could cause punctures or tears (e.g., jewelry, piercings, medical instruments);
  • Weight of the decedent that could cause the bag or bag handle to fail during transport (if available, verify body bag weight capacities as provided by the manufacturer);
  • Bodily fluids posing exposure risks to workers transporting the body should a puncture, tear, or failure occur (taking Standard Precautions for bloodborne pathogens); and
  • Damage or degradation to the body bag that may have occurred in shipment or storage (e.g., the bag is broken or brittle).  

Follow standard routine procedures when transporting the body after bagging. In addition, disinfect the outside of the bag with an EPA-approved disinfectant that meets the criteria for use against SARS-CoV-2, the virus that causes COVID-19, applied according to the manufacturer's recommendations. Wear disposable nitrile gloves when handling the body bag. 

Coroners and medical examiners should continue to work directly with local and county specific resources (such as transporters, EMS service providers, and funeral directors) if they do not have their own dedicated hearse for transporting purposes.

Criteria for COVID-19 Testing

Medical examiners, coroners, and other healthcare professionals should use their judgment to determine if a decedent had signs and symptoms compatible with COVID-19 during life and whether postmortem testing should be pursued. If the diagnosis of COVID-19 was established before death through confirmed laboratory testing, further testing for COVID-19 is not necessary. The decision to test should be based on a combination of clinical and epidemiological factors.
 
Clinical factors include the presence of symptoms of COVID-19, such as cough, shortness of breath or difficulty breathing, and fever. Other symptoms can be found on the Centers for Disease Control and Prevention's website.

There are additional epidemiological factors that may also help guide decisions about COVID-19 testing, such as:

  • documented COVID-19 infections in a jurisdiction,
  • known community transmission,
  • decedent's contact with a person known to have a COVID-19 diagnosis, or
  • decedent being a part of a cluster of respiratory illness in a closed setting (e.g., a long-term care facility).

To review a daily update of a statewide map of Pennsylvanians who have tested positive for COVID-19, please visit the DOH website, Coronavirus page.

Because the symptoms of COVID-19 are similar to symptoms of other respiratory diseases, to increase the likelihood of determining cause of death, testing for other causes of respiratory illness (e.g., influenza) is strongly encouraged.

COVID-19 Testing Laboratories

Coroners and medical examiners may refer cases directly to a commercial laboratory or DOH's Bureau of Laboratories (BOL) for COVID-19 testing, including cases where the decedent does not meet the above criteria but where there is still suspicion that the decedent may have been infected with COVID-19. DOH consultation or approval is not required.

For COVID-19 testing at BOL, follow the instructions on collection and packaging specimens for COVID-19 testing at BOL found here.

A completed specimen submission form must be included with each specimen for BOL testing. Complete contact information should be provided for notification of results.

Collection of Postmortem Clinical and Pathologic Specimens

In its guidance on Collection and Submission of Postmortem Specimens from Deceased Persons with Confirmed or Suspected COVID-19, for suspected COVID-19 cases, CDC recommends collecting and testing postmortem nasopharyngeal swabs (NP swabs) and, if an autopsy is performed, lower respiratory specimens (lung swabs). When collection of an NP swab is not possible, the following are acceptable alternatives:

  • An oropharyngeal (OP) specimen, or
  • A nasal mid-turbinate (NMT) swab collected using a flocked tapered swab, or
  • An anterior nares specimen collected by using a round foam swab. 

To obtain swabs for commercial testing, contact the commercial laboratory or your normal medical equipment supplier. For specimens being tested at BOL, DOH will allocate collection kits.   To order supplies for testing by BOL, fax a completed DOH Supply Order Form for Coronavirus/Influenza Kits to BOL.

The following additional guidance is being provided for the collection of postmortem clinical and pathologic specimens:

  • Maintain proper infection control when collecting specimens.
  • Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing. Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. Refrigerate specimen at 2°-8°C and ship overnight to either the commercial laboratories or the DOH public health laboratory (BOL).
  • For upper Respiratory Tract Specimen Collection, insert a swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to absorb secretions. Swab both nasopharyngeal areas with the same swab. 

If an autopsy is being performed, follow CDC's instructions of "Autopsy Procedures."

Safely Preparing the Specimens for Shipment

After the specimens are collected and properly secured and labeled in primary containers with the appropriate media/solution, they must be transferred from the autopsy suite in a safe manner to laboratory staff who can process them for shipping.

  • Within the autopsy suite, primary containers should be placed into a larger secondary container.
  • If possible, the secondary container should then be placed into a resealable plastic bag that was not in the autopsy suite when the specimens were collected.
  • The resealable plastic bag should then be placed into a biological specimen bag with absorbent material; and then can be transferred outside of the autopsy suite. Workers receiving the biological specimen bag outside the autopsy suite or anteroom should wear disposable nitrile gloves. 

Please also read CDC's interim guidance on "Cleaning and Waste Disposal Recommendations" following an autopsy of a decedent with confirmed or suspected COVID-19.

DOH Reporting Requirements

Communicable Disease Reporting
COVID-19 is a reportable condition in Pennsylvania and must be reported to DOH. All positive and negative laboratory test results, including those for decedents, must be reported to DOH through PA-NEDSS. See the PA-NEDSS webpage for more information on DOH's mandatory electronic disease reporting requirements.
 
Report of Death
Please see State Registrar Notice 2020-02 and 2020-14 for Medical Examiners and Coroners on requirements of reporting COVID-19 deaths that occur in Pennsylvania.
 

CONTACT INFORMATION
Issue Phone Email
COVID-19 Questions877-PA-HEALTH
877-724-3258
RA-DHCOVIDQUESTIONS@pa.gov
EDRS User Account Creation800-323-9613 ra-dhEDRSUserAcct@pa.gov
EDRS Support ra-dhEDRS@pa.gov