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MINISTRYOFHEALTH
KENYA
INTERIMGUIDELINESONHANDLINGOFHUMANREMAINSINFECTEDWITHCOVID-19INKENYA
Thisdocumentwillguideallmortuariesbothpublicandprivate
Theseconsolidatedguidelinesproviderecommendationsforcomprehensive
managementinhandlingofbodiesinfectedwithcovid19
ScopeofGuidelines:
Theguidelineisdesignedtoprovidesupportonthedoesanddon’tstothosehandling
deadbodiesfromthecommunityleveltotheestablishedmortuariesacrossthe
countryinordertominimizetransmissionsduringtheepidemic
Actasaquickstandardreferenceinhandlingdeadbodiesduringthepandemic
Providestandardtoolsfortrackinganddocumentingthesecases
Providestandarddisinfectionanddecontaminationchemicals/solutionsforthe
mortuaryandsitesofdeath
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TargetAudience:
Thosehandlingbodiesofdeceasedpersonsatcommunitylevel,Healthcare,county
andnationallevel.
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FOREWARD
Severeacuterespiratorysyndromecoronavirus2(SARSCO-V2)virusisaNovel
Coronavirusthatwasidentifiedascausingaclusterofpneumoniaanddeathsin
WuhancityinChinaon31stDecember2019.Eventhoughithasbeenfairlywell
controlledinChina,ithascontinuedtocausemorbidityandmortalitiesduetorapid
spreadtootherpartsoftheworld,leadingtotheeventualdeclarationbyWHOthatit
isapandemic.
Thereishenceanurgentneedtohaveguidanceonhowtocontrolthespreadofthe
diseaseinKenya.Kenyahasnotbeensparedbythedisease,withmultiplecasesbeing
reportedinvariouspartsofthecountry.Asof27thMarch2019,onedeathassociated
withthediseasewasreported,thustherequirementtoputupmeasuresonhandling
bodiesofdeceasedpersonsinpreparationforpossiblefatalities.
Thescopeofthisguidelineincludeshandlingofbodiesatcommunitylevel,hospitals,
inmortuaries/funeralhomes,transportationandbodydisposal.
Theseguidelinesarealsosubjecttoreviewaswelearnmoreaboutthediseaseand
measurestoreduceitsspreadandcontainit.
Aswearemanagingthehumanremains,caremustbetakeninformofsafetywhile
alsoensuringthatwepreservedignityofthedeadandbesensitivetothebereaved
andtheirculturalandreligiousbeliefs.
Dr.PatrickAmoth
Ag.DirectorGeneralofHealth
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ACKNOWLEDGEMENTS
ThisInterimGuidelinesonManagementofHumanRemainsinfectedwith
coronavirusdiseasehasbeendevelopedthroughthecontributionsofmany
individualsandinstitutionsthatarecommittedtoensuringeffectivemanagementof
deceasedpersonswithcoronavirusdisease.TheKenyanMinistryofHealth(MOH)
wishestothankallthecontributingauthorsledbythePanelofexpertsonCase
Managementfortheirexpertiseandtimegiventothewritingofthisprotocol.
Dr.LabanThiga
Ag.Director,DirectorateofHealthCarePractice
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TABLEOFCONTENT
Forward………………………………………………………………………………………………………………...3
Acknowledgement……………………………………………………………………………………………….4
ListofAbbreviations……………………………………………………………………………………………...6
Introduction………………………………………………………………………………………………………….7
Bodyhandlingatthecommunitylevelandontransitthisincludesinambulance,privateorpublicvehicle………………………………………………………………………………….……9
Trainingininfectioncontrolandprevention………………………………………………………...11
Bodyhandlinginhospital……………………………………………………………………………………12
Bodyhandlinginthemortuary…………………………………………………………………………….13
Postmortemexamination………………………………………………………………………………….15
Engineeringandenvironmentalcontrolsatautopsy…………………………………………….16
Cleaningofsurfacesandfumigationofautopsysurfacesandrooms………………………17
Transportationofbodies…………………………………………………………………………………….18
Bodydisposal…………………………………………………………………………………………...…………18
Wastedisposal……………………………………………………………………………………………………20
Fumigationoftheplaceofdeath…………………………………………………………………………20
Fumigationofthemortuary…………………………………………………………………………………21
Datahandling…………………………………………………………………………………………………….21
Transportationandhandlingofspecimens…………………………………………………………21
IdentificationofMortuaryHandlers……………………………………………………………………21
Counsellinganddebriefingofpathologistsandmortuaryattendants…………………….22
References……………………………………………………………………………………………………….23
Annexes……………………………………………………………………………………………………………25
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LISTOFABBREVIATIONS
BID– BroughtinDead
HCP–HealthcarePersonnel
MITS–MinimallyInvasiveTissueSampling
NP– Nasopharyngeal
OP- Oropharyngeal
PAPR-Powered,air-purifyingrespirators
PH– PublicHealth
PHO–PublicHealthOfficer
PPE– PersonalProtectiveEquipment
PM– Postmortem
PUI– Personsunderinvestigation
PVC–Polyvinylchloride
SARS–SevereAcuteRespiratorySyndrome
WHO–WorldHealthOrganization
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1.0 INTRODUCTION
Severeacuterespiratorysyndromecoronavirus2(SARS-CoV-2)virusisanoveltype
ofcoronavirusthatwasidentifiedattheendof2019asthecauseofaclusterof
pneumoniacasesinWuhan,acityinHubeiProvinceofChina,witharapidspread
thathasnowbeensporadicallyspreadtootherpartsoftheworld.
OnMarch11th,2020theWorldHealthOrganization(WHO)declareditapandemic
pointingtoover11,800casesofcoronavirusillnessinover110countriesand
territoriesaroundtheworldwithsustainedriskoffurtherglobalspread.WHOhas
putupmeasurestoworkwithaffectedcountriestoreducethespread.Ofnoteisthat
itsclinicalcoursetendstobemildinabout80%oftheaffectedpopulation.Acase
fatalityof2%hasbeenreportedglobally.
Withoutcontainmentmeasures,ithasbeennotedthateachinfectedindividual
infectsonaverage2.5persons.FollowingthefirstreportedcaseinKenyaon13th
March2020theincidencehasbeengrowingexponentiallywithasimilartrendseen
inothercountries.TheindexcasewasthatofatravelervisitingKenyafromthe
UnitedStatesofAmericaviatheUnitedKingdom.TheKenyagovernment
immediatelyputupmeasurestocontainthespread,includingclosureofschoolsand
collegesandbanningofsocialgatherings.
Widespreadcommunitytransmissioncanoverwhelmhealthsystemsresultingin
excessdeaths;therefore,guidelinesarerequiredforthesafemanagementofbodies
ofthedeceasedpersonsinpreparationforpossiblefatalities.Themeasuresinclude
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handlingofbodiesatcommunitylevel,hospitals,inmortuaries/funeralhomes,
transportationandbodydisposal.Completeautopsyofbodieswiththediseaseis
highlydiscouraged.Thiscanonlybedoneinexceptionalcircumstancesafter
consultationandauthorizationfromthediseasesurveillancedepartmentwithinthe
facilityandcountywhichisthenrelayedtotheMinistryofHealthdisasteremergency
responseoperationcenterundertheDirectorGeneral’soffice.
Duringthistimethereneedstobeheightenedcautionandimplementationofstrict
standardinfectionpreventionprotocolsandguidelineswithintheenvironment,hand
hygieneanddecontamination.TheuseofcorrectPPEsisanobligatoryrequirement.
Asexpectedinanynaturaldiseases,manyofinfectedpeoplemaybeasymptomatic
butdieofothercausesincludingaccidents,homicidesorsuicide.Universal
precautionsMUSTbetakenwhilehandlingallbodiestominimizeriskof
transmissiontohealthcareprofessionalsandallmortuaryattendantsinvolvedin
handlingthedeceasedpersons.
Personsdiagnosedwithcoronavirusdiseaseinthehealthcarefacilities,homeorin
otherlocationsmayhaveautopsiesdoneinexceptionalcircumstanceswith
authorizationfromtheChiefGovernmentPathologist.Thesafetyandwell-beingof
everyonewhohandlethesebodiesshouldbethefirstpriority.
Thedignityofthedead,theirculturalandreligioustraditions,andtheirfamilies
shouldberespectedandprotectedthroughout.CulturalaspectsofIslamicreligion
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hasalsobeenannexedinthisdocument,bearingintomindtheinfectioncontrol
practicesandGovernmentregulations.
Thisguidelinewasdevelopedtoprovidegeneralguidanceandsupportin
management(handling)ofthedeadandtotheauthoritiesintheirresponseto
increaseddeathsassociatedwiththepandemicinordertosupporttheHealthcare
Personnelinhandlingofthebodies,disinfectionofthesurfacesanddisposalofthe
bodiesandtissues.Thiswasalsodevelopedtoensuretheprotection,dignityand
respectforthedeceasedindividualsandtheirnextofkin.
Themanagementofdeceasedpersonswithcoronavirusdiseaseshouldnotimpede
themedicolegalinvestigationofdeathwhererequiredbytheauthoritiesbutoffer
additionalhealthandsafetyprecautionshouldbeadoptedforthenecessarypost-
mortemprocedures.
ThestandardsthatarereferencedincludeWHOandotherinstitutionssuchasNIH
andCDC.Notethatthesestandardsaretoenhanceandsupportthedaytoday
practicesatahealthinstitution.Thisdocumentwillcomplementtheinstitutional
Water,SanitationANDhygiene(WASH)andtheInfectionpreventionandcontrol
(IPC)efforts.
Inadditiontotheguidelinehighlightsonenvironmentalsafetyandbiohazardcontrol
areincluded.
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2.0 BODYHANDLINGATTHECOMMUNITYLEVELANDONTRANSITTHIS
INCLUDESINAMBULANCE,PRIVATEORPUBLICVEHICLE
• Onceadeathisencounteredatthecommunitylevel,thefamilyorthe
communitymustnotifythenearesthealthservicedeliverypointimmediately
whothennotifythecountydiseasesurveillancedepartmentwithinthefacility
andcountyofficewhichisthenrelayedtotheMinistryofHealthdisaster
emergencyresponseoperationcenterundertheDirectorGeneral’soffice
• Theregionalpathologistwillbenotifiedbythecountysurveillance
department.Thepathologistwillberesponsibleforsupervisionandguidance
• Thehealthworkermustensurethatthebodyishandledapplyingstrict
standardprecautions,includinghandhygienebeforeandafterinteraction
withthebodyandtheenvironment,anduseofappropriatepersonal
protectiveequipment(PPE)atalltimesplacethebodyintoleakproofand
tamperproofbodybags.
• Ifthereisriskofsplashesfromthebodyfluidsorsecretions,personnelshould
usefacialprotection,includingtheuseoffaceshieldorgogglesandmedical
mask.
• Ensureanybodyfluidsleakingformorificesarecontainedbycomplete
packingwithcottoninfusedwith10%formalinandofalsoincludingusageof
monselsorbandages.
• Keepboththemovementandhandlingofthebodytoaminimum.Thebody
shouldbelabelledandbagged/plasticwrappedimmediatelyintoabodybag.
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• ThebodybagwillbemadeofPVC,leakproofandtamperproofmaterial.
Therewillbedoublebaggingofallbodies
• OncethebodybagbeenwrappeditmustNOTbeopenedthereafter.
• Theoutermostbodybagmustbewipedwith0.5%sodium
hypochlorite/disinfectant.
• TherewillbeNOembalmingtoavoidexcessivemanipulationofthebody.
• ItwillNOTbepermittedwiththisdisease.
• Thebodymustbedisposedoforburiedbythefamilyassoonaspossible
undersupervisionoftheHCP,thelocalHealthcarecommitteeleaderand
religiousleader.
• ThereshouldbeNOsocialorreligiousgatheringinlinewiththePresident’s
directive.
• Itisstronglyrecommendedthatadultsaged60yearsandaboveand
immunosuppressedpersonsshouldnotdirectlyinteractwiththebody
3.0 TRAININGININFECTIONANDPREVENTIONCONTROLMECHANISMS
• Allstaffidentifiedtohandledeadbodiesintheisolationarea,mortuary,
ambulanceandthoseworkersinthecrematorium/burialgroundshouldbe
trainedintheinfectionpreventioncontrolpractices.
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4.0 BODYHANDLINGINHOSPITAL
• Whendeathisconfirmedbytherelevanthealthcareproviders,thebodies
shallbeimmediatelytaggedthenplacedintoleakproofandtamperproof
bodybags.
• Positionpre-openedbodybags(non-porous)nexttohospitalbedona
medicalstretcher/Mortuarystretcher.
• Pullbedsheet(s)upandaroundbody.Donotwashorcleanbody.Remove
insertedmedicalequipment’sfromthebody.
• Gentlyrollbodywrappedinsheetswhileslidingthebodybagunderbody.
• Completetransferofbodytobodybag.
• Zipupbodybagandensureyouminimizeairinbag.
• Disinfectglovedhandsusingalcohol-basedhandrub(ABHR)withaminimum
alcoholconcentrationof70%.
• IfanyareasofPPEhavevisiblecontamination,disinfectwith0.5%Sodium
hypochlorite(bleach).
• Disinfectoutsideofthebodybagwith0.5%Sodiumhypochlorite(bleach).
• Wheelthemedicalstretcher/Mortuarystretchertodecontaminationarea.
• Decontaminatesurfaceofbodybagwith0.5%Sodiumhypochlorite.
• Beginbyapplyingthe0.5%Sodiumhypochloritetotopofbagandany
exposedareasofMedicalstretcher’sorMortuarystretcher.
• Rollthebodybagtoonesidetodecontaminatehalfofbottomofbodybagand
newlyexposedportionoftheMedicalstretcher.
• RepeatwithothersideofbagandMedicalstretcher.
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• Aftercleaningallvisiblesoiledareaswithsoapandwater,reapply0.5%
Sodiumhypochloriteandallow10minutescontacttimeandrinseoffwith
cleanwater.
• Disinfectsurfacesofmedicalstretcher’sorMortuarystretcherfromhandlesto
wheelswiththedisinfectant,cleanwithsoapandwaterthendisinfectwith
0.5%SodiumHypochloriteandallow10minutescontacttimeandrinseoff
withcleanwater.
• Thewheelsofthestretchershouldberolledoveramatsoakedin0.5%
SodiumHypochlorite.
• Disinfectglovedhandsusingbleachsolution(0.5%SodiumHypochlorite).
• Patientidentificationandallothernecessarydocumentsthatneedto
accompanythebodyshouldbeplacedinaziplockbag.
• Affixthefollowinglabelstothebodybagbeforeitisplacedontothehearseor
othervehicleusedtotransportthebody:“infectioussubstance”label
• PushMedicalstretcherandhandoverthedecontaminatedbodybagforburial
• ProceedtoPPEremovalarea.
• Keyconsiderations:
o Strictlyobservestandardinfectionpreventionprecautions
o Appropriatepersonalprotectiveequipment(PPE)mustbeworn
o Donotwashorcleanthebody.
• Thisalsoappliestodeceasedpersonswhoarebroughtindead(BID).
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5.0 BODYHANDLINGINTHEMORTUARY
• AllthebodiesconfirmedtobepositiveforthecoronavirusMUSTbe
immediatelyplacedinadesignatedisolaterefrigeratedchamberwitha
temperatureofbetween2-4degreescentigrade.
• Allbodieswillbeplacedinthesamerefrigeratortocontainspreadandallow
formaximumprecautionsduringhandling.Thereshouldbenocommingling
withotherbodies
• Ensuremortuarystaffapplystandardprecautionsincludingproperhand
hygieneanduseofpersonalprotectiveequipment(PPE).
• Themortuaryattendantmustensurethatthebodyishandledapplying
standardprecautions,includinghandhygienebeforeandafterinteraction
withthebodyandtheenvironment,anduseofappropriatepersonal
protectiveequipment(PPE)atalltimes.
• Ifthereisriskofsplashesfromthebodyfluidsorsecretions,personnelshould
usefacialprotection,includingtheuseoffaceshieldorgogglesandmedical
mask.
• Ensureanybodyfluidsleakingfromorificesarecontainedbycomplete
packingwithcottoninfusedwith10%formalinandofalsoincludingusageof
monselsorbandages.
• Keepboththemovementandhandlingofthebodytoaminimum.
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• Thebodyshouldbelabelledandbagged/plasticwrappedimmediatelyintoa
bodybag.
• Thebodybagwillbemadeofpolyvinylchloride(PVC),leakproofandtamper
proofmaterial.
• Therewillbedoublebaggingandoncethebodybagorplastichasbeen
wrappeditmustNOTbeopenedthereafter.
• ThereshouldbeNOembalmingtoavoidexcessivemanipulationofthebody.
• EmbalmingwillNOTbepermittedwiththisdisease.
6.0 POSTMORTEMEXAMINATION
Thisprocedurewillonlybecarriedoutindesignatedreferralinstitutionsby
adequatelytrainedpersonnelfollowingauthorizationbytheGovernment
Pathologist
• Incaseswherepostmortemexaminationisindicated,suchasdeathin
children,thosewithunusualpresentationslikeCNS,orGITdisease,
communitydeath,deathduringpuerperiumorperipartum.
• Ensurethatstringentsafetymeasuresareputinplacewhileperforming
postmortemexaminationsandcollectingsamples.
• ThePMexaminationshouldbeperformedunderthefollowingguidelines:
• AlimitedPMshouldbedoneinadesignatedisolatedspaceinthemortuary
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• UsetheMinimallyinvasiveprocedurefortissueandfluid/swabsampling
technique
• Identificationcanbecarriedoutusingdigitalmeansofphotosoftheface
andotheridentifierswiththefamilyoutofthemortuary.
• DigitalmediumtobeusedincludecameraforphotographyandTelevision/
LCDdisplayinthemanagementofficefornextofkintoidentifythebody
fromthescreen.Thisistoreducethenumberofpersonsexposedtothe
body.
• Applyappropriatesafetymeasurestoprotectthoseperformingthe
examinations
Engageminimalnumberofstaffintheprocedureandperformonlyif:
• Thereisadequateventilation(useextractorsdoNOTusefans)
• AppropriatePPEisavailable
• Examinethebodywhileinthebodybagtolimitbodymovementand
spillage
• Oncethelimitedautopsyiscompletepackwithcottoninfusedwith10%
formalinwithafocusonpuncturesonthebodyandsealinganyleaking
areaswithcottonwoolincludingusageofmonselsorbandages
• ZIPbagassoonastheprocedureiscompleted.
• ThereshouldbeNOembalming
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7.0 ENGINEERINGANDENVIRONMENTCONTROLSFORAUTOPSY
• Safetyproceduresincasesofdeceasedpersonsinfectedwithcoronavirusdisease
shouldbeconsistentwiththoseusedforanyautopsiesforpeoplewhohavedied
fromanacuteinfectiousrespiratoryillness.
• Ifapersondiedduringtheinfectiousperiodofthecoronavirusdisease,thelungs
andotherorgansmaystillcontainlivevirus,andadditionalrespiratoryprotection
willbeneededduringprocedures
• NegativepressureroomsMUSTbeusedwithcontrolleddirectionofairflowwhen
usingmechanicalventilation,withadequatenaturalorLEDlightingdependingon
timeofday
• Instrumentsusedduringautopsyshouldbecleanedanddisinfectedimmediately
aftertheautopsy,aspartofthestandardroutineprocedure
• Environmentalsurfaceswherethebodywaspreparedshouldfirstbecleaned
withsoapandwateroracommerciallypreparedsolutionwhichislefttosoakon
thesurfacefor10minutes.
• Hospital-gradedisinfectantsmayalsobeusedaslongastheyhavealabelclaim
againstemergingviruses,andtheyremainonthesurfaceaccordingto
manufacturer’srecommendations.
• Aftercleaning,adisinfectantwithaminimumconcentrationof0.1%(1000ppm)
sodiumhypochlorite(bleach)
• PersonnelshoulduseappropriatePPE,includingrespiratoryandeyeprotection,
whenpreparingandusingthedisinfectingsolutions
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• Itemsclassifiedasclinicalwastemustbehandledanddisposedofproperlyand
safelyaccordingtostandardinfectionpreventionandcontrolrequirementsand
legalrequirements
• Onlyaminimumnumberofstaffshouldbeinvolved
• AppropriatePPEmustbeavailable
• UseairextractorsDoNOTuseAirfansinthemortuary
• Referencecentersshallestablishappropriateproceduresforautopsieswitha
strongfocusonbiosafetyasguidedbytheirtechnicalexperts
• DoNOTuseofoscillatingpowersaws
8.0 CLEANINGOFSURFACESANDFUMIGATIONOFAUTOPSYSURFACESAND
ROOMS
• Themortuarymustalwaysbekeptcleanandproperlyventilated
• Soaksurfaceswiththesolutionasfollows:4partssodiumhypochlorite(5.15-
6.15%)sodiumhypochloritesolutionto100partswaterforatleast30minutes
priortocleaning
• CleanALLcleaningsurfaceswithwateranddetergent
• Dofumigationdailyattheendoftheday.ThesolutionsusedareLysoland
formalin
9.0 TRANSPORTATIONOFBODIES
• BaggedBodiesmustbeplacedinabodybagandtheexteriorsurface
decontaminatedfortransportation.
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• BodiesforrepatriationwillfollowIATAguidelinesonhandlingbodieswith
infectiousagents(seereference)
• Oncethebodyhasbeendeliveredtothemortuary,thecasketMUSTbecleaned
anddisinfectedusingthestandardproceduresdescribedearlier.
• ThebodySHOULDNOTbereopenedforviewingthebodyoronceputintothe
casket
• Vehicleusedtodeliverthebodywillfollowthecleaningandfumigationguidelines
asdescribedaboveforthemortuarybeforethevehicleleavesthemortuary,after
theyhavehandedthebodytothemorgue
10.0 BODYDISPOSAL
ThisiscarriedoutstrictlyunderthesupervisionofthePHO/HCP
• ThedisposalofhumanremainsfromCOVID-19casesshouldbeoverseenbya
publichealthofficialwithin2days(48hours)toavoidcommunitypractices
thatwouldresultinmoreinfectionsthroughcontact
• ThehealthworkermustensurethattheCASKETishandledusingthePPEatall
times.ThebodyMUSTNOTbeopenedFORVIEWINGthereafter.
• Thebodymustbeburiedonthesameday,immediatelybythefamilyunder
supervisionoftheHCP,thelocalHealthcarecommitteeleaderandreligious
leader.
• RelativesareSTRICTLYFORBIDDENfromtouchingorkissingthebody.
• Thelocalhealthauthoritiesshoulddesignateateamtooverseetheprocessof
humanremainsdisposalincaseofcoronavirusdiseasedeaths.
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• Asmuchaspossibleminimizehandlingofhumanremainsduringtransportation
• Ensurethatanyonehandlingthebodybagwearssingle-use(disposable)gloves
withextendedcuffsanddoublegloving.
• Coordinatealltransportationofthedeceasedpersonwithcoronavirusdisease
withthelocalhealthofficials
• Asinthecaseofanyotherhighlyinfectiousdisease,avoidtransporting
noncrematedremainsviaaircraft.ThisislinewithIATAguidelines(see
reference)
• Aplanshouldbeinplacetotransportthebodysafelyfromthehospitaltothe
hearseorvehicleusedtotransportthebody.
• Apublichealthofficialshouldbedesignatedinadvancetoaccompanythebody
fromthehospitaltotheplaceoffinaldispositiontoensurethesafetyofallthose
involvedintheprocess.
• Followgovernmentguidanceontheconductoffuneralswhichincludes
minimizingthenumberofattendantstonotmorethanfifteenandmustadhereto
socialdistancing.
• Thereshouldbeproceduresinplacesothedesignatedofficialaccompanyingthe
bodyknowswhattodoifthebodybagiscompromisedduringtransportandhow
tosafelydecontaminateit.
• Thehealthofficialoverseeingthebodydisposalshouldhaveabiohazardspillkit
andrecommendedPPEwithalltheequipmentneededforanysituationinwhich
thebodybagiscompromised
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• Forunclaimedinfectedbodies,theministercaninvokethepublichealthActCAP
242section36(a)and(h)incasesofemergency.
• Theministercanalsobeguidedunderthesamelawonburialofbodiesassoonas
possible.
11.0 WASTEDISPOSAL
• AllmortuarywasteMUSTbepackedintheidealplasticcontainersappropriately
andtransportedsafelyforincinerationundersupervisionbythehospitalPHO.
• TheincinerationMUSTbecarriedoutattheendofeachdaywithoutallowing
wastetolieovernight
12.0 FUMIGATIONOFTHEPLACEOFDEATH
• Incaseofacommunitydeath,theHCPmustorganizeforfumigationbythePH
teamwithin24hours.
• Thefumigationcanbecarriedoutusing10%formaldehydethroughfumigation
aerosolpump.
• Thesitemustbeallowedtoremainuntouchedforatleast24hoursafter
fumigation.
13.0 FUMIGATIONOFTHEMORTUARY
• Use10%formaldehydeandallowtofumigateuntouchedfor24hoursbefore
cleaning.
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14.0 DATAHANDLING
• Allregistersmustbemaintainedasisproceduralformortuaryservices.
• Confidentialityandsafetymustbemaintained
• Alldataonmortalitieswillbesenttotheregionalpathologistthenonwardstothe
GovernmentPathologistofficeusingtheprovideddatacapturesheet(seeannex)
15.0 TRANSPORTATIONANDHANDLINGOFSPECIMENS
• Bestpracticeinspecimencollectingandhandlingmustbeasperthetriple
bagging/packagingwithreferencetotheCDCguidelines
• Thesampleswillbesenttoregionalcentersanddistributedappropriatelyfor
testing.SeeMITSguidelinesonsamplestobecollectedinannexdocument
16.0 IDENTIFICATIONOFMORTUARYHANDLERS
• Alogbookincludingnames,datesandactivitiesofallworkersparticipatinginthe
postmortemandcleaningoftheautopsysuiteshouldbekepttoassistinfuture
followup,asandwhenrequired.
• Includecustodianstaffenteringafterhoursorduringtheday.Seeattached
documentintheannex
• Trackingandidentifyingofmortuaryhandlersisimportantforcontacttracing
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17.0 COUNSELLINGANDDEBRIEFINGOFPATHOLOGISTSANDMORTUARY
ATTENDANTS
• Groupandpersonaldebriefingshouldbecarriedoutatleastonceaweek.
• Atrainedcounsellorshouldbeassignedtothemortuaryforthispurpose.
• Whereamemberofstaffisfoundtobeunabletocopduetostressfromwork,
theyshouldbeadvisedtotaketimeoutforrestusingconventionalreporting
workpolicychannels.
• Areportontheseactivitiesshouldbeforwardedtotheservicemanagerweekly.
• Therewillberegulardebriefingofmortuarystaffandmedicalpractitioners
involvedintheprocess
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17.0REFERENCES
1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-
specimens.htmlCentersforDiseaseControlandPrevention,coronavirusDisease
2019(COVID-19)postmortemGuidelines
2. https://mitsalliance.org/MITS%20Alliance/Toolbox%20docs/PDF%20docs/CHA
MPS_MITS_Spec_SOP_v2.pdfMinimallyInvasiveTissueSamplingProcedure
StandardOperationProcedure
3. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-
methods/chemical.htmlChemicalDisinfectantsGuidelineforDisinfectionand
SterilizationinHealthcareFacilities(2008)
4. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-
specimens.htmlCentersforDiseaseControlandPrevention,CoronavirusDisease
2019(COVID19)PostmortemGuidance
5. IATAguidelinesonDangerousGoods
6. MinistryofHealth,GovernmentofKenya.NationalInfectionPreventionand
ControlGuidelinesforHealthCareServicesinKenya,MOH,MOPH2010
7. Osborn,Michaeletal,BriefingonCOVID-19;Autopsypracticerelatingtopossible
casesofCOVID-19(2019-nCov,novelcoronavirusfromChina2019/2020)Royal
collegeofpathologistsFeb2020
8. WorldHealthOrganization,InfectionPreventionandcontrolofepidemicand
PandemicProneAcuteRespiratoryInfectionsinHealthCare,WHO,2014
9. WorldHealthOrganization,RationaluseofPersonalProtectiveEquipmentfor
CoronavirusDisease2019(COVID-19)interimguide,WHO,February2020
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10. CentersforDiseaseControlandPrevention,Coronavirusdisease2019(COVID19)
PostmortemGuide,CDC,2020
11. MinistryofHealth,GovernmentofIndia,COVID-19:GuidelinesonDeadbody
Management;GovernmentofIndia;MinistryofHealth&FamilyWelfare
DirectorateofHealthServices(EMRDivision),2020
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18.0ANNEX
1.STANDARDPRECAUTIONS
2.MITSKITREQUIREMENTS
3.STANDARDOPERATINGPROCEDUREFORLIMITEDAUTOPSYUSINGTHE
MINIMALLYINVASIVETISSUESAMPLING(MITS)TECHNIQUE
4.ISLAMICGUIDELINESTOHANDLINGSAFEANDDIGNIFIEDBURIALS
5.MORTUARYCHECKLIST
6.DATACAPTURESHEET
7.CLEANINGANDWASTEDISPOSALRECOMMENDATIONS
8.SPECIMENHANDLINGATPOSTMORTEM
9.CASETRACKINGFORMANDDATACAPTUREFORMORTUARYATTENDANTS
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ANNEX1
Standardprecautions
• Handhygiene
o Handusingwithsoapandrunningwaterbeforeandimmediatelyafter
procedures
o Useofalcohol-basedhandrubof70%concentrationandabove
• UseofPPE
o Gloves
§ Wearnonsterile,nitrilegloveswhenhandlingpotentiallyinfectious
materials.
§ Ifthereisariskofcuts,puncturewounds,orotherinjuriesthat
breaktheskin,wearheavy-dutyglovesoverthenitrilegloves.
§ Changeglovesbetweentasks
§ Performhandhygieneaftereveryprocedure
o Facialprotection
§ Useaplasticfaceshieldorafacemaskandgogglestoprotectthe
face,eyes,nose,andmouthfromsplashesofpotentiallyinfectious
bodilyfluids.
§ Avoidcontamination
o Gowns
§ Wearaclean,long-sleevedfluid-resistantorimpermeablegownto
protectskinandclothing.
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§ Removesoiledgownsassoonaspossible
o Masks
§ Alwaysusemedicalmasks(preferableN95)
• Environmentalcontrol
o Disinfection:disinfectantscontainingsodiumhypochlorite,alcohol,
phenoliccompounds,quaternaryammoniumcompoundandoxygen
compounds
• Cleaningofequipment
o Ensuretheyarecleanedanddriedbetweenusage
• Wastemanagement
o StandardColourcodingofsolidwastebins
o Flushliquidwastesorsolidfecalwasteintoseweragesystem
• Preventionofneedle-stickorsharpinjuries
o Standardprecautionslikeuseofsharpdisposalcontainers,never
recappingusedneedles,avoidcarelesshandlingofsharps
29
ANNEX2
MITSKITREQUIREMENTS
MaterialsRequired:MITSSamplecollectionKitComponents
1.Bloodspotcard 10.20G1.5”and18G3.5”spinalpunctureneedleforCSFcollection
2.Photocard 11.20G1.5”and16G1”spinalpunctureneedleforCSFcollection
3.Labelsforsamples 12.20mlsyringesforCSFandbloodcollection
4.BardMonoptyneedle16G,100mm 13.EDTAvacutainer
5.BardMonoptyneedle16G,160mm 14.10mlsteriletubeforCSFandrectalswab
6.Trephinebiopsyneedle 15.2mlcryogenicvialsfortissuemicrobiology
7.Nasopharyngealswabwithviraltransportmedia
16.Large120mlscrewcapjarstorageandtransportoftissuecassettes
8.Rectalbrush 17.Tissuecassettes
9.Personalprotectiveequipment 18.20ml10%NBF(neutralbufferedformalin)
30
ANNEX3
STANDARDOPERATINGPROCEDUREFORLIMITEDAUTOPSYUSINGTHEMINIMALLYINVASIVETISSUESAMPLING(MITS)TECHNIQUE
1.AppropriatepersonalprotectiveequipmentwillbewornbytheMITSpersonnelbeforecommencementofthesamplecollection.
2.Thebodywillbecleanedatthesitesofsamplecollectionandlefttodryforfiveminutesbetweenthecleaningstepsusingcleanwater,70%alcoholandfinallyiodinesolutionrespectively.Thesamplecollectionsitesincludethenose,posteriorcervical/occipitalregion,supra-clavicularregion,axillae,rightupperquadrantregionandtheanus.
3.Cerebrospinalfluidiscollectedfromthecisternmagnumthroughtheoccipitalregionusingthe20Gand18Gspinalneedlesforpaediatricandadultsbodiesrespectivelyanddeliveredtothesteriletubeusingthe20mlsyringe.
4.Nasopharyngealswabsampleisobtainedtrans-nasallyandplacedintothenasopharyngealtubewithviraltransportmedia.
5.Braintissueiscollectedfromtheoccipitalregion(3specimens)andtransnasally(3specimens)usingthe16G160mmBardMonoptyneedle.NB:Thefontanelleswillbeusedtoobtainbrainsamplesininfants.Trans-nasalbrainaccessisachievedafterpenetrationofthecribriformplateusingatrephineneedle.
6.Thefirst3specimens(3occipitaland3trans-nasal)aredeliveredtothecryogenicvialformicrobiologytests.Afurther6braintissuespecimensareobtainedanddeliveredtothe20mlformalinjarforhistologicalanalyses.
7.Bloodsamplecollectioniscarriedoutusing16Gand18Gintramuscularneedlesforinfantsandadultsrespectively.Thespecimenisobtainedthroughthesupraclavicularregionorviadirectheartpuncture.ThebloodisthenputintoanEDTAvacutainerandbloodspotcard.
8.LungtissueiscollectedfromtheaxillaryregionsusingaBardMonopty16G100mmneedle.Thefirstthreeofthespecimensbilaterallyaredeliveredtothecryogenicvialsformicrobiologicaltestswhilethenext6bilaterallyaredeliveredto20mljarsforhistologicalanalyses.NB:Thespecimensareobtainedfromthedifferentlunglobesthroughadjustingtheangulationofthedirectionoftheneedle.
9.Livertissueisobtainedfromthemid-axillarylineatanyofthelast3intercostalspacesusinga16G100mmBardMonoptyneedle.Thefirstthreespecimensobtained
31
aredeliveredtothecryogenicvialsformicrobiologicaltestswhilethenextthreeareputintoa20mlformalinjarforhistologicalanalyses.
10.Rectalstoolsampleisobtainedusingarectalbrushandputina10mlsteriletubeformicrobiologicalanalyses.
11.AftertheMITSspecimencollectioniscompleted,thesamplecontainersareproperlylabelledandplacedinaMITScoolboxforthemicrobiologysamplesandMITSkitboxforthepathologysamplesforonwardtransmissiontothelaboratory.
12.Thebodyiscleanedwith0.5%hypochloridesolutionanddried.Thisisthenplacedintobodybagsandtakenintostorage.
32
ANNEX4
ISLAMICGUIDELINESTOCONDUCTSAFEANDDIGNIFIEDHANDLING&BURIALOFAMUSLIMDECEASEDOROFASUSPECTEDCASEOFCORONAVIRUSDISEASE
RECOMMENDATIONSFORKENYA
TheMuslimscholarshavecometoaconclusionthatinthecaseofthedeceasedofcoronavirus,theobligationsofGhusl(washingofthedead)andKafn(shrouding)canbesuspendedintheeventualityofextremenecessity,duetotheformidablesituationwithaviewtominimisingthespreadofthispandemicandsavingthehumanlives.
IslamiclawhighlyvaluesallprecautionsissuedbyanyDepartmentofHealthinthisregard.Inconsequence,thedeceasedofthisvirusistobeburiedwithoutghuslandkafnifrequired,andJanazah(Prayerforthedead)wouldbeperformedinthegraveyardfromaconvenientdistanceatthetimeofburialbyafewindividualsifpossible,ormaybeofferedafterburialathisgrave.Orawayfromthegraveinabsentia.AstheProphetprayedtheJanazaprayerforNegus(AbysynianKing)inabsentia.
Henceintheseextenuatingcircumstanceswewouldencouragethisasanalternativeforthosewhoarenotabletoattendtheprayerinpersonofafamilymemberorfriend.
Allahknowsbest.
STEPSTOBETAKEN:
NOTE:DeceasedMuslimsshouldnotbecrematedorplacedinthebodybagnaked.
•ADryAblution(Tayamum)canbeperformedbyaMuslimmemberoftheburialteamonthedeceasedpatientbeforebeingplacedinthebodybag.OtherwiseaMuslimperson/familymembercanperformthissimpleprocedureoncetheyhavebeenplacedinthebodybag.
•Thedeceasedpatientisshroudedbywrappinginaplainwhitecottonsheetbeforebeingplacedinthebodybag.Theshroudshouldbeknottedatbothends.
•FemalemembersoftheBurialteamshouldshrouddeceasedfemalepatientspriortoplacinginabodybag.
33
•PermissioncanbesoughtinadvancefromtheImamthatthebodybagcanbeusedtorepresentashroud.WhitebodybagsshouldbeusedforMuslimpatients.
SHROUDING(KAFN)
•Aplainunstitchedwhitecottonsheet(scentedwithmusk,camphororperfumed)isplacedontopoftheopenedbodybag.
•ThedeceasedisliftedbytheBurialteamandplacedontopoftheshroud.
•Theextendedsideedgesoftheshroudarepulledoverthetopofthedeceasedtocoverthewholebody,i.e.thehead,body,legsandfeet.
•Threestripscutfromthesamefabricareusedtotieandcloseuptheshroud.Oneforabovethehead,oneforbelowthefeetandoneforaroundthemiddleofthebody.Itisknottedatbothends.
•FemalemembersoftheBurialteamshouldshroudthedeceasedfemalepatients.
•Thebodybagisclosed.
Collectionofsoiledobjects,disinfectionifneeded,orburningandcleaninganddisinfectionoftheenvironment(rooms,house)wearingPPE
1.Collectanysharpsthatmighthavebeenusedonthepatientanddisposetheminaleak-proofandpunctureresistantcontainer.
2.Cleanwithcleanwateranddetergentandthendisinfectwithasuitabledisinfectant(e.g.,0.5%chlorinesolution)allroomsandannexesofthehousethatwerepossiblyinfectedbythedeceasedpatient.Specialfocusshouldbegiventoareassoiledbyblood,nasalsecretions,sputum,urine,stoolandvomit.
3.Cleanwithwateranddetergentallobjects(e.g.dishes…)possiblyinfectedbythedeceasedpatient;thendisinfectwithachlorinesolution0.5%.
4.Gatherinaplasticbag,bedlinen,clothesandobjectsofthedeceased,ifany.Ensurethebagistightlyclosedanddisinfected.
34
5.Mattresses,strawmatssoiledwithbodyfluidofthedeceasedpatientshouldbeburntatadistancefromthehouse.Ensurethefamilyhavegivenpermissiontodestroythemattresses,strawmat,etc.
Attheendofthisstepallplacesinthehomearedisinfected
6.Familytocommunallywashhandswithdisinfectantaftertheburial(usingchlorinesolution0.05%ormakeanalcohol-basedhand-rubsolutionavailableforhandhygieneperformance)forallmembersinvolvedinthefuneralprocess.
NECESSARYEQUIPMENTTOPREVENTINFECTIONS
Handhygiene:
•Alcohol-basedhandrubsolutionOF70%andabove(recommended)OR
•Cleanrunningwater,soapandtowels(recommended)OR
•Chlorinesolution0.05%(whenoptionabovearenotavailable)
PersonalProtectiveEquipment(PPE):
•Onepairofdisposablegloves(non-sterile,ambidextrous)
•Onepairofheavydutygloves
•Disposablecoverallsuit(e.g.Tyvecsuit)+impermeableplasticapron
•Faceprotection:gogglesandmask
Footwear:
-Rubberboots(recommended)ORifnotavailable
-Shoeswithpuncture-resistantsolesanddisposableovershoes
Wastemanagementmaterials:
•Disinfectant:
�Onehandsprayer(0.05%chlorinesolution)
�Onebacksprayer(0.5%chlorinesolution)
•Leak-proofandpunctureresistantsharpscontainer
35
•Twoleak-proofinfectiouswastebags:onefordisposablematerial(destruction)andoneforreusablematerials(disinfection)
Revisedby:
1.Sh.MuhammadSwalihu,Imam,JamiaMosque,Nairobi.
2.Sh.AbdulrahmanIs’haq,Imam,ParklandsMosque,Nairobi.
3.Sh.IbrahimRasheed,Imam,SalaamMosque,SouthC,Nairobi.
4.Sh.MuhdharHussein,Imam,AthiRiverMosque,Mavoko.
5.Sh.AbdullatifA.Sheikh,FamilyResourceCentre,JamiaMosque,Nairobi.
25thMarch,2020.
36
ANNEX5
CHECKLISTFORMORTUARYROOMSATDIFFERENTLEVELS
1.MORTUARYWITHCAPACITYTOCARRYOUTAUTOPSIESLEVELIV
Thebasicsettingforamortuaryshouldincludeadissectionroom,viewingroom,thefreezingrooms,thestaffroom,managementoffice,consumable/suppliersstore,reception,toilets,changingrooms,specimenstorageroom
Reception/medicalrecords:
1Chair
1Table
Boxfiles
Desktop
Printer
Handwashsink
Bookshelf
Codedwastebins
Waitingroom
Chairs
Codedwastebins
Chapel/Hall/auditorium
Chairs
Codedwastebins
Counsellingroom
37
Officedeskand2chairs
Bookshelf
Codedwastebins
Managementoffice
2Chairs
1officeTable
Boxfiles
Desktop
Printer
Handwashsink
Bookshelf
CodedWasteBins
DissectionRoom
Footdeepboxwithtoiletbrush
Officetable
Hangingshelfwithdocumentstodotheautopsyforpersonconductingautopsy
Handwashsink
Aluminum/terazoDissectiontable/swithrunningtapwaterandadrain
AluminumbodyTrolley
Aluminum/terazoWorktopwithrunningtapwateranddrainorgrossstationwithrunningtapwateranddrain
Dissectionkit
Oscillatorwithafumehood/aerosolprotector
38
Hacksaw
Choppingboard
Weighingscale
Measuringcylinders
Whiteboardforthewall
Cameraandaudiorecordingequipment
CCTV/glasswallforauditorium
Aluminummobilespecimenandinstrumenttrolley
Storagecupboards
Sharpsbins
Generalwastebin(stepbin)–colourblack[generalwaste]
CodedWasteBins(stepbin)–coloryellow[infectiouswaste]
CodedWastebin(stepbin)–colourred[anatomicalpathologicwaste]
AirExtractororNegativepressureroom
Widewindowsfornaturallight/LEDlight/UVdecontaminationlighting
Imagingservices
Portablex-raymachineswithascanner
CTScan/MRItobesourcedfromthemainhospitalasandwhenneeded
Sluicespace
Sinkwithrunningtapwaterandadrain
Autoclaveandhigh-leveldecontaminationfacility
Macerators
Worktopwithterrazzo/aluminum
39
AirExtractororNegativepressureroom
Codedwastebins
Specimenstorageroom/Transitionarea
Terazoworktop
Buckets
Basins
Shelves
Codedwastebins
Consumablestore
Storageshelves
Officetableandchair
Codedwastebins
Changingrooms
Malechangingroom
Femalechangingroom
Cupboards/lockers
Boots
Scrubs
Masks
Gloves
Eyeprotectivegoogles
Haircapes
40
Disposablegowns
Shoecovers
Hazmatsuit
PowerrespiratorswithHEPAfilters
Disposablewaterproofaprons
Codedwastebins
Toilets
StaffMaletoilets
StaffFemaletoilets
Publictoilets
Codedwastebins
Freezerroom
ManualhoistingAluminumbodytrolley
Simplealuminumtrolley
Whiteboard
Refrigerators
Staffroom/tearoom
Tables
chairs
Codedwastebins
41
2.PRIVATE/COMMUNITYLEVELMORGUELEVELIIANDIII
Thebasicsettingforamortuaryshouldincludeadissectionroom,viewingroom,thefreezingrooms,thestaffroom,managementoffice,consumable/suppliersstore,reception,toilets,changingrooms,specimenstorageroom
Reception/medicalrecords
1Chair
1Table
Boxfiles
Desktop
Printer
Handwashsink
Bookshelf
Codedwastebins
Waitingroom
Chairs
Codedwastebins
Chapel/Hall/auditorium
Chairs
Codedwastebins
Counsellingroom
Officedeskand2chairs
42
Bookshelf
Codedwastebins
Managementoffice
2Chairs
1officeTable
Boxfiles
Desktop
Printer
Handwashsink
Bookshelf
CodedWasteBins
DissectionRoom
Footdeepboxwithtoiletbrush
Officetable
Hangingshelfwithdocumentstodotheautopsyforpersonconductingautopsy
Handwashsink
Aluminum/terazoDissectiontable/swithrunningtapwaterandadrain
AluminumbodyTrolley
Aluminum/terazoWorktopwithrunningtapwateranddrainorgrossstationwithrunningtapwateranddrain
Dissectionkit
Oscillatorwithafumehood/aerosolprotector
Hacksaw
Choppingboard
43
Weighingscale
Measuringcylinders
Whiteboardforthewall
Aluminummobilespecimenandinstrumenttrolley
Storagecupboards
Sharpsbins
Generalwastebin(stepbin)–colourblack[generalwaste]
CodedWasteBins(stepbin)–coloryellow[infectiouswaste]
CodedWastebin(stepbin)–colourred[anatomicalpathologicwaste]
AirExtractororNegativepressureroom
Widewindowsfornaturallight/LEDlight/UVdecontaminationlighting
Sluicespace
Sinkwithrunningtapwaterandadrain
Autoclaveandhigh-leveldecontaminationfacility
Macerators
Worktopwithterrazzo/aluminum(Canholdsamplestemporarily)
AirExtractororNegativepressureroom
Codedwastebins
Consumablestore
Storageshelves
Officetableandchair
Codedwastebins
44
Changingrooms
Malechangingroom
Femalechangingroom
Cupboards/lockers
Boots
Scrubs
Masks
Gloves
Eyeprotectivegoogles
Haircapes
Disposablegowns
Shoecovers
Hazmatsuit
PowerrespiratorswithHEPAfilters
Disposablewaterproofaprons
Codedwastebins
Toilets
StaffMaletoilets
StaffFemaletoilets
Publictoilets
Codedwastebins
Freezerroom
ManualhoistingAluminumbodytrolley
45
Simplealuminumtrolley
Whiteboard
Refrigerators
Staffroom/tearoom
Tables
chairs
Codedwastebins
4.LEVELIFACILITY
ThebasicsettingforalevelIfacilityshouldincludeaholdingroomandviewingroom,thestaffroom,managementoffice,consumable/suppliersstore,reception,toilets,changingrooms
Holdingroom
Asimplelockableroom.
SizeMINIMUM10BY20FEETroom
Nootherstorageshouldbedoneinthisroom
Terazofloor
Reception/medicalrecords
1Chair
1Table
Boxfiles
Desktop
Printer
46
Handwashsink
Bookshelf
Codedwastebins
Waitingroom
Chairs
Codedwastebins
Managementoffice
2Chairs
1officeTable
Boxfiles
Desktop
Printer
Handwashsink
Bookshelf
CodedWasteBins
Consumablestore
Storageshelves
Officetableandchair
Codedwastebins
Changingrooms
Malechangingroom
47
Femalechangingroom
Cupboards/lockers
Boots
Scrubs
Masks
Gloves
Eyeprotectivegoogles
Haircapes
Disposablegowns
Shoecovers
Hazmatsuit
PowerrespiratorswithHEPAfilters
Disposablewaterproofaprons
Codedwastebins
Toilets
StaffMaletoilets
StaffFemaletoilets
Publictoilets
Codedwastebins
Staffroom/tearoom
Tables
chairs
Codedwastebins
48
ANNEX6
DATACAPTURESHEET,CORONAVIRUSDISEASEPOSTMORTEMS
49
ANNEX7
CLEANINGANDWASTEDISPOSALRECOMMENDATIONS
Thefollowingaregeneralguidelinesforcleaningandwastedisposalfollowinganautopsyofadecedentwithconfirmedorsuspectedcoronavirusdisease.Currentevidencesuggeststhatnovelcoronavirusmayremainviableforhourstodaysonsurfacesmadefromavarietyofmaterials.
Routinecleaninganddisinfectionprocedures(e.g.,soakingthesurface,usingcleanersandwatertocleansurfaces)shouldbedonepriortoapplyingEnvironmentalProtectionAgency(EPA)approveddisinfectantthatexpectedtobeeffectiveagainstCOVID-19basedondataforhardertokillvirusesinthesesettings.
Afteranautopsyofadecedentwithconfirmedorsuspectedcoronavirusdisease,thefollowingrecommendationsapplyfortheautopsyroom(andanteroomifapplicable):
• Keepventilationsystemsactivewhilecleaningisconducted• Weardisposabledoubleglovesrecommendedbythemanufacturerofthe
cleanerordisinfectantwhilecleaningandwhenhandlingcleaningordisinfectingsolutions.
• Disposeofglovesassoonastheybecomedamaged,whensoiledandwhencleaningiscompleted,asdescribedbelow.
• NEVERWASHORREUSEGLOVES.• Useeyeprotection,suchasafaceshield,gogglesorfacemask,ifsplashingof
water,cleaner/disinfectant,orotherfluids,isexpected.• Wearaclean,long-sleevedfluid-resistantgowntoprotectskinandclothing.• WearaNIOSH-certifieddisposableN-95respiratororhigherifyouneedto
cleantheroom.• AdditionalPPEmayberequiredtoprotectworkersagainstpotentialhazards
associatedwiththecleaninganddisinfectantproductsusedandinaccordancewiththelabelinstructions.
• Whenrespiratorsarenecessarytoprotectworkers,employersmustimplementacomprehensiverespiratoryprotectionprograminaccordancewiththeOSHARespiratoryProtectionstandard(29CFR1910.134externalicon)thatincludesmedicalexams,fittesting,andtraining.
• UsedisinfectantthatisexpectedtobeeffectiveagainstCOVID-19basedondataforhardertokillviruses.Followthemanufacturer’sinstructionsforallcleaninganddisinfectionproducts(e.g.,concentration,applicationmethodandcontacttime,etc.).
50
• Soakthesurfacefirstthencleanthesurfaceandthenapplythedisinfectantasinstructedonthedisinfectantmanufacturer’slabel.
• Ensureadequatecontacttimeforeffectivedisinfection.• Adheretoanysafetyprecautionsorotherlabelrecommendationsasdirected
(e.g.,allowingadequateventilationinconfinedareasandproperdisposalofunusedproductorusedcontainers).
• Avoidusingproductapplicationmethodsthatcausesplashingorgenerateaerosols.
• Cleaningactivitiesshouldbesupervisedandinspectedperiodicallytoensurecorrectproceduresarefollowed.
• Donotusecompressedairand/orwaterunderpressureforcleaning,oranyothermethodsthatcancausesplashingormightre-aerosolizeinfectiousmaterial.
• Grosscontaminationandliquidsshouldbecollectedwithabsorbentmaterials,suchastowels,bystaffconductingtheautopsywearingdesignatedPPE.
Grosscontaminationandliquidsshouldthenbedisposedofasdescribedbelow:
• Useoftongsandotherutensilscanminimizetheneedforpersonalcontactwithsoiledabsorbentmaterials.
• Largeareascontaminatedwithbodyfluidsshouldbetreatedwithdisinfectantfollowingremovalofthefluidwithabsorbentmaterial.Theareashouldthenbesoaked,cleanedandthendisinfected.
• Smallamountsofliquidwaste(e.g.,bodyfluids)canbeflushedorwasheddownordinarysanitarydrainswithoutspecialprocedures.
• Hard,nonporoussurfacesmaythenbecleanedanddisinfectedasdescribedabove.
• FollowstandardoperatingproceduresforthecontainmentanddisposalofusedPPEandregulatedmedicalwaste.Nationalandcountygovernmentsshouldbeconsultedforappropriatedisposaldecisions.
• Disposeofhumantissuesaccordingtoroutineproceduresforpathologicalwaste.
• Cleananddisinfectorautoclavenon-disposableinstrumentsusingroutineprocedures,takingappropriatestandardprecautionswithsharpobjects.
• Materialsorclothingthatwillbelaunderedcanberemovedfromtheautopsysuite(oranteroom,ifapplicable)inasturdy,leak-proofbiohazardbagthatistiedshut,labelledclearlyandnotreopened.Thesematerialsshouldthenbesentforlaunderingaccordingtoroutineprocedurestakingwithutmostprecautioninfectionpreventionandcontrolmeasures.
51
• Washreusable,non-launderableitems(e.g.,aprons)withdetergentsolutiononthewarmestsettingpossible,rinsewithwater,decontaminateusingdisinfectant,andallowitemstodrycompletelybeforenextuse.
• Keepcamera,telephones,computerkeyboards,andotheritemsthatremainintheautopsysuite(oranteroom,ifapplicable)ascleanaspossible,buttreatasiftheyarecontaminatedandhandlewithgloves.
• WipetheitemsafterusewithappropriateEnvironmentalProtectionAgency(EPA)-approveddisinfectantthatareexpectedtobeeffectiveagainstCOVID-19.
• Ifbeingremovedfromtheautopsysuite,ensurecompletedecontaminationwithappropriatedisinfectantaccordingtothemanufacturer’srecommendationspriortoremovalandreuse.
• WhencleaningiscompleteandPPEhasbeenremoved,washhandsimmediatelywithsoapandwaterfor20seconds.
• Alwayswashhandswithsoapandwaterbeforeusingalcohol-basedhandsanitizeof70-95%concentration.
• Avoidtouchingthefacewithglovedorunwashedhands.• HandhygienefacilitiesMUSTbereadilyavailableatthepointofuse(e.g.,ator
adjacenttothePPEdoffingarea).
52
ANNEX8
SPECIMENCOLLECTIONFORPOSTMORTEM
Mostoften,spreadfromalivingpersonhappenswithclosecontact(i.e.,withinabout6feet)viarespiratorydropletsproducedwhenaninfectedpersoncoughsorsneezes,similartohowinfluenzaandotherrespiratorypathogensspread.Thisrouteoftransmissionisnotaconcernwhenhandlinghumanremainsorperformingpostmortemprocedures.
Postmortemactivitiesshouldbeconductedwithafocusonavoidingaerosol,dropletdepositsonfomitesgeneratingprocedures,andensuringthatifaerosolgenerationislikely,appropriateengineeringcontrolsandpersonalprotectiveequipment(PPE)areused.Theseprecautionsandtheuseofstandardoperatingproceduresshouldensurethatappropriateworkpracticesareusedtopreventdirectcontactwithinfectiousmaterial,percutaneousinjury,andhazardsrelatedtomovingheavyremainsandhandlingembalmingchemicals.
A.CollectionofPostmortemUpperRespiratoryTractSwabSpecimenswhenMITSisbeingperformed
Collectionofthefollowingpostmortemspecimensisrecommendedifnotperformingautopsy:
• PostmortemclinicalspecimensfortestingforSARS-CoV-2,thevirusthatcausesCOVID-19,toincludeonlyupperrespiratorytractswabs:
• NasopharyngealSwabAND• OropharyngealSwab(NPswabandOPswab)• SeparateNPswabandOPswabspecimensfortestingofotherrespiratory
pathogens• Individualsintheroomduringtheprocedureshouldbelimitedtohealthcare
personnel(HCP)obtainingthespecimen.• IfHCParenotperforminganautopsyorconductingaerosolgenerating
procedures(AGPs),followStandardPrecautions.
53
EngineeringControlRecommendations:
Sincecollectionofnasopharyngealandoropharyngealswabspecimensfromdeceasedpersonswillnotinducecoughingorsneezing,anegativepressureroomisrequired.PersonnelshouldadheretoStandardPrecautionsasdescribedabove.
PPERecommendations:
ThefollowingPPEshouldbewornataminimum:
• Wearnonsterile,doublenitrilegloveswhenhandlingpotentiallyinfectiousmaterials.
• Ifthereisariskofcuts,puncturewounds,orotherinjuriesthatbreaktheskin,wearheavy-dutyglovesoverthenitrilegloves.
• Wearaclean,long-sleevedfluid-resistantorimpermeablegowntoprotectskinandclothing.
• Useaplasticfaceshieldorafacemaskandgogglestoprotecttheface,eyes,nose,andmouthfromsplashesofpotentiallyinfectiousbodilyfluids.
B. Autopsyprocedures
StandardPrecautions,ContactPrecautions,andAirbornePrecautionswitheyeprotection(e.g.,goggles,facemaskorafaceshield)shouldbefollowedduringautopsy.Manyofthefollowingproceduresareconsistentwithexistingguidelinesforsafeworkpracticesintheautopsysetting.
• AerosolizedGeneratingProceduressuchasuseofanoscillatingbonesawisNOTrecommendedforconfirmedorsuspectedcasesofCOVID-19.
• Considerusinghandshearsasanalternativecuttingtool.• Allowonlyonepersontocutatanygiventime.• Limitthenumberofpersonnelworkingintheautopsysuiteatanygiventime
totheminimumnumberofpeoplenecessarytosafelyconducttheautopsy.• Limitthenumberofpersonnelworkingonthehumanbodyatanygiventime.• Useabiosafetycabinetforthehandlingandexaminationofsmallerspecimens
andothercontainmentequipmentwheneverpossible.• Usecautionwhenhandlingneedlesorothersharps,anddisposeof
contaminatedsharpsinpuncture-proof,labeled,closablesharpscontainers.• Alogbookincludingnames,dates,andactivitiesofallworkersparticipatingin
thepostmortemandcleaningoftheautopsysuiteshouldbekeptassistinginfuturefollowup,asandwhenrequired.
• Includecustodianstaffenteringafterhoursorduringtheday.
54
PPERecommendations:
ThefollowingPPEshouldbewornduringautopsyprocedures:
• Doublesurgicalglovesinterposedwithalayerofcut-proofsyntheticmeshgloves
• Fluid-resistantorimpermeablegown• Waterproofapron• Gogglesorfaceshield• NIOSH-certifieddisposableN-95respiratororhigher• Powered,air-purifyingrespirators(PAPRs)withHEPAfiltersmayprovide
increasedworkercomfortduringextendedautopsyprocedures.• Whenrespiratorsarenecessarytoprotectworkers,employersmust
implementacomprehensiverespiratoryprotectionprogram.BeforeuseofitemstheHCPmustbetrainedandproperlyfit
• Surgicalscrubs,shoecovers,andsurgicalcapshouldbeusedperroutineprotocols.Doff(whichmeanstakingoffPPE),PPEshouldbetakenoffcarefullytoavoidcontaminatingyourselfandbeforeleavingtheautopsysuiteoradjacentanteroom.
AfterremovingPPE,discardthePPEintheappropriatelaundryorwastereceptacle.ReusablePPE(e.g.,goggles,faceshields,andPAPRs)mustbecleanedanddisinfectedaccordingtothedisinfectionguidelinesbeforereuse.ImmediatelyafterdoffingPPE,washhandswithsoapandwaterfor20seconds.Alwayswashhandswithsoapandwaterbeforeusingalcohol-basedhandsanitizerof70-95%alcohol.Avoidtouchingthefacewithglovedorunwashedhands.Ensurethathandhygienefacilitiesarereadilyavailableatthepointofuse(e.g.,atoradjacenttothePPEdoffingarea).
CollectionofPostmortemClinicalSpecimensforSARS-CoV-2Testing
CDCrecommendscollectingandtestingpostmortemupperrespiratoryspecimens(nasopharyngealandoropharyngealswabs)and,ifanautopsyisperformed,lowerrespiratoryspecimens(lungswab).
MaterialsandMethods
i. Useonlysyntheticfiberswabswithplasticshafts.
ii. Donotusecalciumalginateswabsorswabswithwoodenshafts,astheymaycontainsubstancesthatinactivatesomevirusesandinhibitPCRtesting.
55
Swabbingmethod
i.Nasopharyngealswab
• Insertaswabintothenostrilparalleltothepalate.Leavetheswabinplaceforafewsecondstoabsorbsecretions.Swabbothnasopharyngealareaswiththesameswab.
ii.Oropharyngealswab(e.g.,throatswab)
• Swabtheposteriorpharynx,avoidingthetongue.
iii.Lowerrespiratorytract:Lungswabs
• Collectoneswabfromeachlung.
Specimenpacking
i.Placeswabsimmediatelyintosteriletubescontaining2-3mlofviraltransportmedia.
ii.NP,OP,andlungswabspecimensshouldbekeptinseparatevials.Refrigeratespecimenat2-8°CandsendtotheLaboratoryperformingthetestingonicepack.
iii.UpperRespiratoryTractSpecimenCollection:NasopharyngealSwabANDOropharyngealSwabs(NPswab,OPswab)
CollectionofPostmortemClinicalSpecimensforOtherRoutineDiagnosticTesting
Separateclinicalspecimens(e.g.,NPswab,OPswab,lungswabs)shouldbecollectedforroutinetestingofrespiratorypathogensateitherclinicalorpublichealthlabs.NotethatclinicallaboratoriesshouldNOTattemptviralisolationfromspecimenscollectedfrompersonsunderinvestigation(PUIs)forcoronavirusdisease.
Otherpostmortemspecimencollectionandevaluationsshouldbedirectedbythedecedent’sclinicalandexposurehistory,sceneinvestigation,andgrossautopsyfindings,andmayincluderoutinebacterialcultures,toxicology,andotherstudiesasindicated.
SafelyPreparingtheSpecimensforTransport
Aftercollectingandproperlysecuringandlabelingspecimensinprimarycontainerswiththeappropriatemedia/solution,theymustbetransferredfromtheautopsysuiteinasafemannertolaboratorystaffwhocanprocessthemfortransport.
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1.Withintheautopsysuite,primarycontainersshouldbeplacedintoalargersecondarycontainer.
2.Ifpossible,thesecondarycontainershouldthenbeplacedintoaresealableplasticbagthatwasnotintheautopsysuitewhenthespecimenswerecollected.
3.Theresealableplasticbagshouldthenbeplacedintoabiologicalspecimenbagwithabsorbentmaterial;andthencanbetransferredoutsideoftheautopsysuite.
4.Workersreceivingthebiologicalspecimenbagoutsidetheautopsysuiteoranteroomshouldweardisposablenitrilegloves.
SubmissionofPostmortemClinicalSpecimensforSARS-CoV-2Testing
ThissectionappliestosubmissionofpostmortemNPswab,OPswab,andlungswabs
•Storespecimensat2-8°Candshipovernighttoauthorizedlaboratoriesonicepack.
•Labeleachspecimencontainerwiththepatient’sIDnumber(e.g.,medicalrecordnumber),uniquespecimenID(e.g.,laboratoryrequisitionnumber),specimentype(e.g.,tissue),andthedatethesamplewascollected.
•Completeaspecimensubmissionformforeachspecimensubmitted.
Paraffin-embeddedtissueblocks
• Ingeneral,thisisthepreferredspecimenandisespeciallyimportanttosubmitincaseswheretissueshavebeeninformalinforasignificanttime.
• Prolongedfixation(>2weeks)mayinterferewithsomeimmunohistochemicalandmoleculardiagnosticassays.
Wettissue
• Ifavailable,wehighlyrecommendthatunprocessedtissuesin10%neutralbufferedformalinbesubmittedinadditiontoparaffinblocks.
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ANNEX9
CASETRACKINGFORM
NAMEOFINSTITUTION:
KMPDCNO:
PERSONIN-CHARGE:
StaffNo. Date Name Age Telephonenumber
NextofKin:Fullnameandnumber
Designation Role/ActivitywiththeCOVID19case
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LISTOFCONTRIBUTORS
NAME ORGANIZATION
DRLABANTHIGA MINISTRYOFHEALTH
PROF.EMILYROGENA JOMOKENYATTAUNIVERSITYOFAGRICULTUREANDTECHNOLOGY/KACP
DR.JOHANSENODUOR MINISTRYOFHEALTH/KACP
DR.EDWINWALONG UNIVERSITYOFNAIROBI/KACP
DR.NOELLEORATA MOUNTKENYAUNIVERSITY/KACP
DR.SERAHKAGGIA JOMOKENYATTAUNIVERSITYOFAGRICULTUREANDTECHNOLOGY/KACP
DR.EVELYNCHEGE MINISTRYOFHEALTH/KACP
DR.GEOFFREYOMUSE AGAKHANUNIVERSITY
DANIELKIMANI CENTERSFORDISEASECONTROLKENYA
EVELYNWESANGULA MINISTRYOFHEALTH
FELISTERKIBERENGE CENTERSFORDISEASECONTROLKENYA
LOYCEKIHUNGI ITECHKENYA
MERCYNJERU CENTERSFORDISEASECONTROLKENYA
VERONICAKAMAU MINISTRYOFHEALTH
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MINISTRYOFHEALTHKENYAASSOCIATIONOFCLINICALPATHOLOGISTS
MinistryofHealth
AfyaHouse,CathedralRoad,
P.O.Box30016-00100,
Nairobi,Kenya
Telephone:+254-20-2717077
Email:[email protected]
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