Eric Coomes MDDivision of Infectious DiseasesDepartment of MedicineUniversity of Toronto

COVID-19: Primer for funeral, cemetery and cremation industry

COVID -19 Update – March 23Steven Reynolds – President, OACFP

Carey Smith – Registrar & CEO, Bereavement Authority of Ontario

Registrar’s Update … COVID-1923 March 2020

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COVID-19: Primer for funeral, cemetery and cremation industry Eric Coomes MDDivision of Infectious DiseasesDepartment of MedicineUniversity of Toronto

Disclosures

• None

Objectives• Review the literature regarding SARS-CoV-2 and

COVID-19

• Review the best practices for COVID-19 as it pertains to funeral, cemetery, and cremation industries

Coronavirus• RNA viruses

• 4 strains endemic globally Cause of “common cold” 10-30% of URTIs

• Highly pathogenic coronaviruses from animal reservoirs MERS SARS

(Paules, JAMA, 2020)

Bats, Wildlife, and SARr-CoVs• Coronaviruses have been identified in many animal hosts

• Diverse SARS-related-CoVs live in bats in regions globally

• SARS and COVID-19 epidemics started at a Chinese wildlife markets.

(Wang, 2018; Wang, 2007)

COVID-19:Time course

December 31: Wuhan notifies WHO of 27 cases of pneumonia

of unknown cause

January 1: Huanan Seafood Market Closed

January 7: CDC China confirm coronavirus etiology and

sequence virus

January 9: China shares coronavirus sequences; 1st death

January 13: 1st international case (Thailand)

January 15: China CDC emergency response upgraded to level 1

January 16: Strict exit screening in Wuhan

January 19: First case in another Chinese province

(Li, NEJM, 2020)

Epidemiological curves of COVID-19 in China through February 11, 2020.

January 19: First case in another Chinese province

January 21: Human-to-human transmission

confirmed

January 28: > 55 million people

quarantined over 16 cites in Hubei

January 30: WHO declares Public Health Emergency

Continuous common source Propagated source

(Wu, JAMA, 2020)(China CDC, 2020)

Jan 23: Wuhan

Quarantined

• Global > 300,000 cases

• China > 80,000 cases

• Italy > 50,000 cases

• Canada > 1000 cases

WHO. COVID-19 Situation Report – 50. March 10, 2020

COVID-19:Clinical Features

Clinical Characteristics of COVID-19SymptomsFever (hospitalization) (87.9%)Fever (admission) (43.1%)Cough (67.7%)Fatigue (38.1%)Sputum (33.4%)Dyspnea (18.6%)Myalgia / Arthralgia (14.8%)

Sore throat (13.9%)Chills (11.4%)Nausea/Vomiting (5%)Nasal congestion (4.8%)Diarrhea (3.7%)Hemoptysis (0.9%)Conjunctival injection (0.8%)

(Guan, NEJM, 2020)* Amongst 1099 laboratory-confirmed COVID-19 cases in China

Clinical Characteristics of COVID-19SymptomsFever (hospitalization) (87.9%)Fever (admission) (43.1%)Cough (67.7%)Fatigue (38.1%)Sputum (33.4%)Dyspnea (18.6%)Myalgia / Arthralgia (14.8%)

Sore throat (13.9%)Chills (11.4%)Nausea/Vomiting (5%)Nasal congestion (4.8%)Diarrhea (3.7%)Hemoptysis (0.9%)Conjunctival injection (0.8%)

(Guan, NEJM, 2020)* Amongst 1099 laboratory-confirmed COVID-19 cases in China

National Control Responses• Encourage handwashing and mass masking

• Proactive surveillance (testing all patients with atypical pneumonia)

• Rapid diagnostics and case-isolation • Rigorous mandatory quarantine of close contacts (and

regions)

• Social distancing Stopping mass gatherings Closure of educational and workplace institutions

(WHO-China Joint Mission, 2020)(Anderson, Lancet, 2020)

Chain of Transmission

Reservoir• Humans (Living or Deceased)

• Equipment or surfaces contaminated with body fluids

Portals of Exit + Entry• Secretions + ExcretionsOral (saliva)Respiratory secretions (cough / sputum)

• Unknown:BloodFecal-oral

Transmission: Droplet and Contact

(WHO-China Joint Mission, 2020)

How to break the chain?

Routine practices• All deceased remains are potentially infectious

• Goal(s):Prevent spread of infectionPrevent exposure to blood, body fluids, secretions, etc.

Routine practices• Administrative controls (i.e. policies, education)• Risk assessment• Hand hygiene• Personal protective equipment• Environmental controls

If you feel unwell…do NOT come to work.

…even a mild cough, sore throat, or fever needs to stay at home

Risk Assessment• Assess the risk of exposure to blood, body fluids, and non-intact skin.

• How to determine if deceased patient was COVID positive? Medical Certificate of Death However, do not have full history and routine practice is

to treat every deceased as potentially infectious

Hand Hygiene• Most important and effective measure• Gloves do NOT replace hand hygiene• Perform hand hygiene before and after engaging in any task where a risk of exposure exists i.e. any contact with deceased, fluids, or transport

Personal Protective Equipment• Gloves – Hands in contact with mucous membranes, non-intact

skin, bodily fluids, contaminated equipment/surfaces Clean hands before putting on gloves Do not reuse gloves

• Gowns + Mask + Eye Protection When the procedure is likely to generate splashes of

blood, body fluids, secretions, or excretions

CDC Advice Direct contact with deceased:1) Nitrile gloves when handling potentially

infectious materials (deceased / fluids)2) Long-sleeved fluid-resistant or impermeable

gown to protect skin and clothing.3) Plastic face shield or face mask + goggles

CDC Advice: Transport• Nitrile gloves “Workers receiving the biological specimen bag outside the autopsy suite or anteroom should wear disposable nitrile gloves”

PPE: Special Circumstances• Airborne transmission may occur in the setting ofaerosol generating procedures

• If aerosol generating procedure – use N95 i.e. use of oscillating saw

Cleaning + Waste Management• PPE for cleaning area which had direct contact with

deceased (or fluids): Gloves Clean long-sleeved fluid resistant gown Eye protection Surgical mask

• Do not use compressed air or water pressure that cause aerosolization

• Use disinfectants with label claims against human coronaviruses

Cleaning + Waste Management• Dispose of human tissues according to routine procedures for pathological waste

• Clean and disinfect or autoclave non-disposable instruments using routine procedures

• Wash reusable, non-launderable items (e.g., aprons) with detergent solution, decontaminate using disinfectant, rinse with water, and allow items to dry before next use

General Workplace Strategies• Promote handwashing For employees and clients Display posters Sanitizing dispensers around workplace

• Physical distancing Maintain > 6 feet between persons Avoid gatherings – use virtual meetings

• Increased frequency of cleaning public surfaces (desks/tables/telephones)

Strategies for Gatherings• Minimize number of attendees Fewer is better

• Offer virtual or live-streamed participation• Consider entry screening If symptomatic – offer mask and redirect

• Stagger arrivals and departures Reduce number of attendees at any given time

• Close food and beverage service areas • Handwashing stations

What if you have symptoms?

Assessment

HTTPS://COVID-19.ONTARIO.CA/SELF-

ASSESSMENT/#Q1TELEHEALTH (1-866-797-0000)

Q&A – Virus on surfaces / bodies?• Question: “After death, how long do you think the SARS-CoV-2 could be retrievable in cadavers, if they are kept in the morgue (4 degrees) or not?”

• Kampf et al. identified that coronaviruses (not SARS-CoV-2) can survive up to 9 days on inanimate surfaces at room temperature

• However, at 4 degrees, coronaviruses can persist for > 28 days

Viruses on surfaces• Doremalen et al. looked at SARS-CoV-2 survival on

surfaces

• Survival at room temperature on inanimate surfaces for up to 3 days

• Viable virus was detected up to 72 hours after application on inanimate surfaces Virus titer was markedly reduced after 48 hours on stainless steel No viable virus was measure after 4 hours on copper or 24 hours on

cardboard More stable on plastic and steel than copper and cardboard

Q&A – Casket + Flowers• If direct contact with body or bodily fluids – then potential for contact transmission

• Consider disinfection of external surfaces • If handling surfaces that have been in direct contact with body or bodily fluids – wear gloves for PPE

Q&A – Which disinfectant?• Check product label for activity against coronaviruses

• Coronaviruses can be efficiently inactivated by surface disinfection procedures with:62-71% ethanol0.5% hydrogen peroxide 0.1% sodium hypochlorite

Q&A –Will cremation kill the virus?• Heat is highly active at destroying virus. • Heat at 56°C kills the SARS coronavirus quickly • Cremation occurs at ~ 1000 degrees Celsius – the virus would be very rapidly and completely eradicated under such conditions.

• Transportation before cremation should follow routine procedures. If inside a sealed body bag, then only gloves are

required

Q&A – Need for masks at funerals?• Not routinely recommended • No evidence on the usefulness of face masks worn by healthy/asymptomatic persons

• Symptomatic persons should be offered a mask May consider redirecting symptomatic guests

• Practice “social distancing”

Questions?

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Thank You

OACFP Response to Covid-19 - March 23 2020 57