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embalming fluid, and coffins. This can affect the ability of professionals to adhere strictly to IPAC protocols and may require triaging of essential resources. Shortages of PPE have been observed globally during the COVID-19 pandemic, particularly for surgical masks and filtering facepiece respirators, and where these shortages occur, priority for accessing additional supply is given to health care providers involved in caring for infected patients. This could place death care providers, usually private businesses, in a difficult position of being unable to access PPE essential for protection of both their employees and family members or religious officials who wish to participate in preparation of the deceased for burial or cremation. Pandemics can evolve over time and may have multiple waves that can overwhelm local resources and capabilities (Smith, 2016). This can include death care personnel who may need to work long hours under difficult conditions. Death care personnel who have not received training on infectious diseases or whose training is out of date may also be underprepared to manage a rapid increase in deceased that require additional precautions. A survey of funeral industry workers in Ireland found that infectious disease was the most important workplace health and safety issue although respondents indicated a lack of understanding in relation to transmission routes for some infectious diseases (Kelly & Reid, 2011). A more recent study of death care sector workers in the United States identified that only one-third of respondents had been trained on how to manage bodies of persons who had died from highly infectious diseases (Le et al., 2017). Less than 60% of respondents had protocols and procedures in place for selection of appropriate PPE based on the risk of highly infectious diseases. More than half of respondents did not use filtering facepiece respirators as PPE, and of those that did, less than half performed appropriate fit testing. The survey also indicated that industry-specific training and education on handling of infectious disease or high-risk cases was several years out of date. Where mass casualties reach levels in excess of what funeral homes can accommodate, additional personnel may be needed to help process the deceased and assist with temporary storage of bodies or administrative measures. Strained systems may require the use of volunteers or redeployment of workers from other sectors (Scanlon et al., 2007). These individuals may not be trained in standard protocols associated with the management of infection disease, including the appropriate use of PPE. To minimize risk to volunteers or deployed persons, appropriate training on infection prevention and control principles and correct use of PPE should be considered. Mass fatality events can present additional demand for cremation and burial services. An increase in cremation activity may give rise to public health complaints about noise, odour, or air quality concerns (O’Keeffe, 2020) but aside from this, facilities may not be able to keep up with demand. If processing and disposition of the deceased by cremation or burial cannot be achieved in a timely and dignified manner, options for temporary storage or holding of the deceased may be required. Morgue storage is usually temporary, for a few days at 4–8°C; however, alternative cold storage options may be needed for up to 6 months during a mass fatality event (Smith, 2016). Refrigeration temperatures between 2 and 4°C are identified as the most appropriate by the Pan American Health Organization (PAHO) (Cordner et al., 2016). Storage locations can include conventional facilities such as morgues or less conventional holding areas such as cold storage warehouses, hangars, refrigerated trucks or rail cars, refrigerated shipping containers, hockey or curling rinks, or other novel cooling or racking systems (Anderson et al., 2017; Cordner et al., 2016; Ontario Ministry of Health and Long-Term Care, 2020). For each of these options, power requirements should be assessed to ensure ample power supply can be maintained and there are contingencies in place for loss of power (Anderson et al., 2017). Consideration should be made of how feasible it is to return these temporary facilities to their original use after being used for the storage of bodies. For example, cold storage food warehouses or refrigerated grocery trucks may not be quickly returned to their original use without thorough consideration of appropriate cleaning and disinfection measures (Cordner et al., 2016). Where suitable temporary storage cannot be found, a last resort can be temporary burial. Cordner et al. (2016) recommend burial at least 1.5 m deep, at least 200 m from drinking water sources, with trenches at least 0.4 m apart, and bodies should not be stacked. Bodies should be appropriately labelled and location marked clearly on a map or plan so they can be readily retrieved (Finegan et al., 2020). In the short term, temporary measures necessary for death care practices to prevent transmission of infectious diseases during a pandemic include additional precautions related to contact with the deceased and minimizing possible exposure to droplets and bodily fluids by reducing manipulation and handling of the body where possible. While more research is needed to fully understand how long the SARS-CoV-2 virus remains viable
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