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

25

10. CentersforDiseaseControlandPrevention,Coronavirusdisease2019(COVID19)

PostmortemGuide,CDC,2020

11. MinistryofHealth,GovernmentofIndia,COVID-19:GuidelinesonDeadbody

Management;GovernmentofIndia;MinistryofHealth&FamilyWelfare

DirectorateofHealthServices(EMRDivision),2020

26

18.0ANNEX

1.STANDARDPRECAUTIONS

2.MITSKITREQUIREMENTS

3.STANDARDOPERATINGPROCEDUREFORLIMITEDAUTOPSYUSINGTHE

MINIMALLYINVASIVETISSUESAMPLING(MITS)TECHNIQUE

4.ISLAMICGUIDELINESTOHANDLINGSAFEANDDIGNIFIEDBURIALS

5.MORTUARYCHECKLIST

6.DATACAPTURESHEET

7.CLEANINGANDWASTEDISPOSALRECOMMENDATIONS

8.SPECIMENHANDLINGATPOSTMORTEM

9.CASETRACKINGFORMANDDATACAPTUREFORMORTUARYATTENDANTS

27

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.

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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.

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.

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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:ps@health.go.ke

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