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The primary mode of person-to-person transmission of SARS-CoV-2 remains to be via direct contact with an infected person and their respiratory emissions (droplets and aerosols), and secondarily via contact with contaminated surfaces (fomites), followed by touching of the eyes, mouth, or nose.24-26 Transmission may also be possible following exposure to aerosols during aerosol generating procedures (AGP) performed on a COVID-19 patient. In the absence of active respiratory emissions from a dead body, exposure to infectious droplets or aerosols or indirect contact transmission may occur due to the following:27-29 Contact with contaminated fomites where sufficient viable virus to cause infection is transferred from a surface to the eyes, mouth, or nose of a susceptible host. Movement or manipulation of the body during handling or transfers, causing shifting of the respiratory cavity, resulting in possible sporadic emission of air or fluids. The International Committee of the Red Cross (ICRC)9 designated certain death care activities during the COVID-19 pandemic as low, medium, or high risk based on the potential for exposure to SARS-CoV-2 virus. Low-risk activities include those where there is minimal direct contact with the deceased such as during admission to the funeral home, preparation of the body for viewing, and release of the deceased for burial or cremation, which could result in contact with fomites. Medium-risk activities include rolling, undressing, or significant manual handling of the body, or other low-risk activity that results in inadvertent droplet generation (e.g., splashing of spilled fluid during admission to a funeral home), which could result in contact with droplets or contaminated fomites. High-risk activities include those such as autopsy or other invasive procedures, including embalming, and AGPs that could result in direct inhalation of droplets or aerosols or contact with bodily fluids of the deceased and contact with contaminated fomites. The Occupational Safety and Health Administration’s (OSHA) occupational risk pyramid also designates workers performing AGPs or collecting/handling specimens from decedents known or suspected to be infected with COVID-19 at the time of death as the highest risk category among death care occupations.30 A review of the current evidence on the COVID-19 risks to death care personnel and others who may have physical contact with COVID-19 decedents is needed to continue to inform measures to mitigate risks. Methods A rapid literature search was performed to identify recent evidence of persistence of SARS-CoV-2 post-mortem, transmission events resulting from handling of dead bodies, and evidence on incidence of COVID-19 infection or mortality associated with death care occupations. Ebscohost databases (includes Medline, Cinahl, Academic Search Complete, etc.) Google Scholar, and Google, with a date limit focus of May 1, 2020 to Dec 31, 2021 (to account for e-pubs ahead of print), no jurisdictional limit, and English language documents were scanned. Further examination of bibliographies of key articles was used to retrieve more extensive information, and forward chaining of key papers added to the search results. Variants and Boolean operator combination of the following key search terms were used: (corpse OR cadaver OR mortuary OR funeral OR cemetary OR cemetery OR burial OR “death care” OR deceased OR bereavement OR memorial OR “dead bodies” OR “dead body” OR cremation OR greening OR morgue OR “preserving human remains” OR “body disposal” OR tahara OR “transporting bodies” OR open-casket OR “open casket” OR post-mortem OR autopsy); (undertaker OR caretaker OR “funeral industry worker” OR “funeral director” OR “funeral professional” OR embalmer OR embalm OR forensic OR “medical personnel” OR paramedic OR “ambulance driver OR “body preparation”); (virus OR coronavirus OR ncov OR "novel cov” OR COVID-19 OR SARSCOV-2 OR Sars-Cov-19 OR SarsCov-19 OR SARSCOV2019 OR "severe acute respiratory syndrome cov 2" OR "2019 ncov” OR "2019ncov” OR COV-2); (transfer OR spread OR infect OR infection OR transmission OR transmit OR contagious OR touch OR shed OR shedding OR secretion); (survival OR survive OR persist OR persistence OR viability); (tissue OR skin OR saliva OR mucous OR eye OR cell OR kidney OR testis OR clothing OR blood OR lung OR fomite). Additional grey literature and government websites reporting on COVID-19 infection, death or risk factors by occupation were also scanned for information relevant to death care professions and expert advice was sought on key resources relevant to Canada. How long does SARS-CoV-2 persist on the surface of a body or in bodily tissues or fluids that may be encountered post-mortem? Where a person has died from an infectious respiratory virus, risk of transmission to others may depend on the quantity and the viability of the virus within the lungs and other bodily tissues and fluids, on the surface of the body, or on fomites that may be contaminated with droplets or bodily fluids from the deceased. Risks of infection from a dead body due to improper handling are greater soon after death when pathogens may still be viable but will decrease over time as viral replication in live cells ceases and the biochemistry of cells change, causing viable
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