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decedents under biosafety level 3 conditions.61 Kritselis and Remick (2020) reviewed the potential transmission of respiratory disease during autopsy. They found no evidence for transmission to laboratory personnel during the SARS and MERS pandemics, and limited risk of infection in the COVID-19 pandemic for autopsy personnel when appropriate precautions are used.62 The present review examined literature on autopsies of COVID-19 decedents where follow-up of COVID-19 outcomes (positive test, illness, hospitalization, or mortality) were reported for personnel involved. No evidence of onward transmission among autopsy personnel was identified in these reports, although this represents only a small sample of all autopsies performed throughout the pandemic.32,37,63-65 Davis and Williamson (2020) report on a survey of approximately 200 listserv pathologists on COVID-19 outcomes for persons performing autopsies on deceased patients with COVID-19.66 Of 225 autopsies, most involving multiple autopsy staff, only one person reported having developed COVID-19 infection. None of the 12 other personnel working in the same morgue developed symptoms or tested positive for COVID-19,and it was postulated that the infected person may have been exposed in the community, rather than during autopsies.66 This report should be treated with some caution and considered an anecdotal account of experiences of a selected group of US pathologists. Without further supporting information such as the type and duration of exposure, safety protocols applied, and the level of follow-up for detecting onward transmission in each of the 225 autopsies reported, firm conclusions cannot be drawn.67 For non-autopsy-related death care occupations, no additional literature was identified that reported on COVID-19 outcomes for personnel involved. Literature reporting on incidence of COVID-19 across general occupational groups provides some insight into which occupations experience proportionally higher levels of COVID-19-related illness or death, but no literature was identified that reported on death care occupations in Canada.68,69 International studies that assess COVID-19 incidence and mortality across occupational units vary widely in the level of granularity reported, but no evidence of higher rates among death care professions was identified.70-74 Occupations related to “social and personal services” or “personal care and service occupations,” which include death care occupations, have a higher level of physical proximity and frequency of contact compared to some other occupations, and may also have higher likelihood of exposure to disease. A retrospective analysis of COVID-19 incidence by occupation in Washington State by Zhang (2021) found that the characteristics of “exposure to disease” and “physical proximity to others” were correlated with COVID-19 case prevalence among workers.74 Others have used occupational characteristics such as these to identify the occupations at highest risk for COVID-19 infection. Using the United States occupational classification database (O*Net), healthcare occupations were identified to be among the top 15 highest risk occupations for COVID-19 infection.75,76 Among non-healthcare occupations, “morticians, undertakers and funeral directors” were listed as 8th highest and “embalmers” as 13th highest of 15 non-healthcare professions.75,76 Despite these classifications, evidence of heightened incidence of COVID-19 infection or mortality has not been identified among death care professions covered by these categories, suggesting that measures to mitigate risks are being successfully applied. Excess deaths throughout the COVID-19 pandemic have increased the handling of dead bodies required by death care professionals. Handling of COVID-19 decedents has required heightened awareness of standard precautions and good practice to reduce transmission risks, and a precautionary approach has typically been taken where the COVID-19 status of a deceased person is unknown. Concerns raised about the risk of infection among death care personnel due to contact with dead bodies prompted this rapid review of evidence of COVID-19 transmission in the death care sector.77 The expanding literature on the presence of SARS-CoV-2 viral RNA in or on a dead body indicates that the virus may be present in a wide array of bodily tissues and fluids and can be detected at extended intervals of several hours to days post-mortem. Detection of viral RNA does not necessarily equate to a risk of transmission leading to infection but provides an indicator of tissues and fluids that may present a risk. Further study is needed to understand the presence and duration of viability of virus in various tissues and fluids, as well as likelihood of indirect transmission occurring. To date, with over two million COVID-19 deaths reported worldwide, there have been no confirmed reports of SARS-CoV-2 transmission from a dead body to a living host, including among persons with the greater risk of exposure, namely autopsy personnel. Current data does not indicate that post-mortem examinations and autopsies of COVID-19 patients are resulting in secondary transmission to personnel involved in these procedures. Current approaches to mitigating risks appear to be successful in preventing
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