ministry of health kenya - government of kenya...the kenya government immediately put up measures to...
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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
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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)
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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
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aredeliveredtothecryogenicvialsformicrobiologicaltestswhilethenextthreeareputintoa20mlformalinjarforhistologicalanalyses.
10.Rectalstoolsampleisobtainedusingarectalbrushandputina10mlsteriletubeformicrobiologicalanalyses.
11.AftertheMITSspecimencollectioniscompleted,thesamplecontainersareproperlylabelledandplacedinaMITScoolboxforthemicrobiologysamplesandMITSkitboxforthepathologysamplesforonwardtransmissiontothelaboratory.
12.Thebodyiscleanedwith0.5%hypochloridesolutionanddried.Thisisthenplacedintobodybagsandtakenintostorage.
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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.
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•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.
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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
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•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.
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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
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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
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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
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AirExtractororNegativepressureroom
Codedwastebins
Specimenstorageroom/Transitionarea
Terazoworktop
Buckets
Basins
Shelves
Codedwastebins
Consumablestore
Storageshelves
Officetableandchair
Codedwastebins
Changingrooms
Malechangingroom
Femalechangingroom
Cupboards/lockers
Boots
Scrubs
Masks
Gloves
Eyeprotectivegoogles
Haircapes
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Disposablegowns
Shoecovers
Hazmatsuit
PowerrespiratorswithHEPAfilters
Disposablewaterproofaprons
Codedwastebins
Toilets
StaffMaletoilets
StaffFemaletoilets
Publictoilets
Codedwastebins
Freezerroom
ManualhoistingAluminumbodytrolley
Simplealuminumtrolley
Whiteboard
Refrigerators
Staffroom/tearoom
Tables
chairs
Codedwastebins
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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
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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
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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
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Changingrooms
Malechangingroom
Femalechangingroom
Cupboards/lockers
Boots
Scrubs
Masks
Gloves
Eyeprotectivegoogles
Haircapes
Disposablegowns
Shoecovers
Hazmatsuit
PowerrespiratorswithHEPAfilters
Disposablewaterproofaprons
Codedwastebins
Toilets
StaffMaletoilets
StaffFemaletoilets
Publictoilets
Codedwastebins
Freezerroom
ManualhoistingAluminumbodytrolley
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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
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Handwashsink
Bookshelf
Codedwastebins
Waitingroom
Chairs
Codedwastebins
Managementoffice
2Chairs
1officeTable
Boxfiles
Desktop
Printer
Handwashsink
Bookshelf
CodedWasteBins
Consumablestore
Storageshelves
Officetableandchair
Codedwastebins
Changingrooms
Malechangingroom
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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
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ANNEX6
DATACAPTURESHEET,CORONAVIRUSDISEASEPOSTMORTEMS
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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.).
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• 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.
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• 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).
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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.
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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.
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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.
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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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