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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


April 7, 2020


TO:
Local Health Officers
Local Registrars of Births and Deaths
Chief Deputy Registrars of Births and Deaths
County Coroners
Funeral Establishments and Related Providers [1]

SUBJECT:
Infection Prevention for Funeral Establishments Handling Deceased Cases of COVID-19


Background

This document is intended to provide guidance for preventing infection in funeral establishments and the workers who handle deceased persons with coronavirus disease 2019 (COVID-19), the illness caused by SARS-coronavirus-2 (SARS-CoV-2).  SARS-CoV-2 can cause severe and fatal respiratory illness, but approximately 80 percent of cases are mild. Asymptomatic cases may still be infectious.

The best prevention is frequent handwashing with soap and water. COVID-19 is most often spread by respiratory droplets when an infected person coughs or sneezes, similar to how influenza and other respiratory infections spread. Transmission from respiratory droplets is not a concern when handling human remains or performing postmortem procedures. However, funeral establishment workers and others who handle decedents should take precautions to avoid contact with potentially infectious bodily fluids and inhalable aerosols during transfers and embalming.

This guidance recommends additional protective measures and equipment to best protect funeral establishment workers and others who handle decedents. When a death occurs due to COVID-19, no funeral director or embalmer shall charge any additional fees for handling or embalming a decedent. [2]

Preventing Contact with Infectious Bodily Fluids

The Centers for Disease Control and Prevention (CDC) and the Occupational Health and Safety Administration (OSHA) recommend using a combination of standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles or face shields) to protect funeral establishment workers and others who handle decedents from exposure to the virus. The Cal/OSHA Aerosol Transmissible Diseases standard requires respiratory protection during aerosol-generating procedures.

Funeral establishment and other workers who have contact with the remains of people who have died from COVID-19 infection must be protected from exposure to infected blood and bodily fluids, fecal material, contaminated objects, and contaminated environmental surfaces.

 At a minimum, funeral establishment and other workers should:

  • Wear nonsterile, nitrile gloves when handling potentially infectious materials.
  • Wear heavy-duty gloves over the nitrile gloves if there is a risk of cuts, puncture wounds, or other injuries that break the skin.
  • Wear a clean, long-sleeved fluid-resistant or impermeable gown to protect skin and clothing.
Use a plastic face shield or a face mask and goggles to protect the face, eyes, nose, and mouth from splashes of potentially infectious bodily fluids.

Transferring Human Remains

  • When a healthcare facility contacts you about making a removal, ask whether there are any precautions you need to follow when you arrive.
  • When entering a home of a person who is known or suspected to be infected with COVID-19, maintain social distancing of six feet or more from other people. Request that ill household members put on a facemask and stay in a room with the door closed, away from the funeral establishment professional.
  • When lifting and moving the body, because of the possibility that air may be expelled from the body, the face of the deceased should be covered temporarily with a disposable surgical mask or cloth and the body placed in a body bag. Enclosing the deceased in a body bag also contains body fluids to prevent contact.  
  • Wear disposable nitrile gloves when handling the body bag.
  • Disinfect the outside of the body bag with a product that meets EPA's criteria for use against SARS-CoV-2.

Preventing Exposure to Infectious Aerosols

COVID-19 could potentially be transmitted by infectious aerosols generated when suctioning bodily fluids or doing other aerosol generating procedures. If aerosol generating procedures are anticipated, refer to US Centers for Disease Control and Prevention's guidance for postmortem specimens from deceased persons under investigation for COVID-19 for information on procedures that should be avoided, additional safety precautions, ventilation requirements, and respiratory protection.

Embalming

Embalming can be conducted. In the preparation room, make sure the ventilation fan is on and use a ventilated table if available. During embalming, follow Standard Precautions including the use of additional personal protective equipment (PPE) if splashing is expected (e.g., disposable gown, plastic apron, face shield or goggles, and waterproof boots or shoe covers). Embalming involves the aspiration of blood and other body fluids from the body which results in the generation of aerosols. Wear respiratory protection for procedures that generate aerosols and if required for chemicals. For protection against respirable aerosols, wear a surgical N95 filtering face piece respirator, an elastomeric respirator equipped with N95 or P-100 filters, or a powered air purifying respirator equipped with HEPA filters. If a respirator is not obtainable, wear a surgical mask. Wear heavy-duty gloves over nitrile disposable gloves if there is a risk of cuts, puncture wounds, or other injuries that break the skin.

Disposition

Decedents with COVID-19 can be buried or cremated.

Cleaning and Disinfection for COVID-19

Use an Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant for routine cleaning and disinfection. Follow the instructions on the label and disinfect all equipment and surfaces potentially contaminated with infectious fluids, including the body bag. Use appropriate personal protective equipment (PPE) and respiratory protection following the disinfectant instructions for use.

COVID-19 and Funerals

  • Refer to the CDPH Guidance for the Prevention of COVID-19 Transmission for Gatherings and Face Coverings when considering holding a service for the families. If a service is held, social and physical distancing practices of six feet between individuals should be observed for those that are coming together on a one-time basis. Counties may impose additional restrictions on the total number of individuals that may attend a funeral service.
  • People should consider not touching the body of someone who has died of COVID-19. Older people and people of all ages with severe underlying health conditions are at higher risk of developing serious COVID-19 illness. There may be less of a chance of the virus spreading from certain types of touching, such as holding the hand or hugging after the body has been prepared for viewing. Other activities, such as kissing, washing, and shrouding should be avoided before, during, and after the body has been prepared. If washing the body or shrouding are important religious or cultural practices, families are encouraged to work with their community cultural and religious leaders and funeral home staff on how to reduce their exposure as much as possible. At a minimum, people conducting these activities should wear disposable gloves. If splashing of fluids is expected, additional personal protective equipment (PPE) may be required (such as disposable gown, face shield or goggles and face mask).

 Resources

 For any questions regarding infection prevention for handling deceased cases of COVID-19 please contact the California Department of Public Health at novelvirus@cdph.ca.gov.

[1] This includes cemeteries, crematories, and decedent transportation providers.
[2] California Business and Professions Code Section 7685.1 

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