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virus to diminish.31,32 Persistence of SARS-CoV-2 in bodily tissues and fluids post-mortem Several studies have reported on the detection of SARS-CoV-2 viral RNA in dead bodies. The presence of viral RNA does not necessarily indicate the presence of infectious virus.33 Viral RNA has been shown to diminish over time but may still be detected after viral particles cease to be infectious.34 SARS-CoV-2 RNA has been detected several days post-mortem on eyes, 34,35 nose, and mouth,36 periodontal tissue,37 and the respiratory tract including the nasopharynx, throat, and lungs,18,38-42 and other bodily tissues and fluids.43 Aquila et al. (2021) detected SARS-CoV-2 RNA in oropharyngeal, nasal, and bronchial specimens collected at time intervals of 2, 4, 6, 12 and > 24 hours after death in the majority of 20 decedents with confirmed COVID-19 infection at time of death, with the number of positive results decreasing over time.32 Rodic and Tahir (2020) detected a positive result for SARS-CoV-2 one day post-mortem, and subsequently one day post-embalming, indicating that embalming (replacement of blood with formaldehyde-based chemicals) does not preclude detection of virus, and care should be taken even post-embalming.41 Only one study was identified that reported on the viability of SARS-CoV-2 virus in post-mortem specimens, which indicated viable virus was detected up to 35.8 hours post-mortem in the throat of some patients40,44 Persistence of SARS-CoV-2 on skin Few studies have measured how long SARS-CoV-2 virus can remain viable on skin. One study used swine skin as a surrogate for human skin, finding that SARS-CoV-2 remained stable for up to 14 days at 4°C, 96 hours at 22°C, and 8 hours at 37°C.45 In comparison, a study measuring viability on human skin collected from autopsy specimens, approximately one day after death, found that mean survival time for SARS-CoV-2 was 9 (± 1) hours at 25°C.46 The reasons for the difference in viability at room temperature for these two studies (96 versus 9 hours respectively) is unclear but may be related to experimental conditions such as dosing volume (50 µl versus 5 µl respectively) and skin preparation. Persistence of SARS-CoV-2 on other surfaces (fomites) Several studies have measured the persistence of SARS-CoV-2 on common surfaces under experimental conditions.47-51 The virus appears to remain viable for longer periods (one to seven days or more) on smooth, hard surfaces such as stainless steel, hard plastic, glass, and ceramics and for shorter periods (several hours to two days) on porous materials such as paper, cardboard, and textiles. Persistence determined under experimental conditions may be dependent on other factors such as the initial volume and dose deposited, which may not be representative of real-world conditions.45,47-55 Ambient temperature also has a significant effect on persistence, with SARS-CoV-2 remaining viable for longer under cool conditions as indicated in these experimental studies. No studies were identified that assessed whether viable SARS-CoV-2 virus is present on surfaces or objects present in rooms/facilities where dead bodies are stored, examined, or prepared for burial or cremation. The available evidence suggests that viable virus may remain in or on the body for several hours to a few days post-mortem, but contamination of surfaces with viable virus may depend on whether leaks, splashes, sprays, or aerosolization of bodily fluids or tissues have occurred. Is there evidence for transmission of SARS-CoV-2 from a deceased person to others? The rapid literature search found no evidence of a confirmed case of transmission of COVID-19 from a deceased person to date.1,7,56,57A short communication in April 2020 reported the possible transmission from a deceased COVID-19 patient to a forensic examiner in Thailand. This report was later revised to clarify that transmission from the corpse to the examiner was a possibility only, and the pathway was not confirmed.58,59 In May 2020, a funeral home worker in Atlanta claimed to have been infected with SARS-CoV-2 following transport and preparation of a deceased COVID-19 patient at a funeral home, resulting in his hospitalization 17 days following contact with the body. No details of other potential exposure routes or an epidemiological investigation were provided in the news report.60 Is there evidence that persons involved in the handling, transport, and examination of decedents are at higher risk of COVID-19 infection or mortality? The risk of transmission of SARS-CoV-2 from deceased bodies was identified to be greatest for persons who may be exposed to contaminated surfaces, respiratory droplets or bodily fluids of COVID-19 decedents, with persons involved in conducting autopsies or other invasive procedures, including AGPs, to be at the highest risk, as described previously.9,27,30 A systematic review by Yaacoub et al. (2020) on the effectiveness of procedures for safe handling of COVID-19 decedents found no primary studies reporting on COVID-19 outcomes for death care workers. Only one primary study (low certainty of evidence) was included in the review originating from the SARS pandemic, which found no evidence of adverse outcomes for 23 pathologists and technicians involved in autopsies of 16 SARS-CoV
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