Rangkuman

A review of the management and safe handling of bodies in cases involving COVID-19

“With an increasing number of deaths being recorded due to this pandemic, the International
Committee of the Red Cross has indicated that deaths caused by COVID-19 could overwhelm
local capacity to properly handle dead bodies. It suggested that to overcome this risk, proper
preparation and planning is essential so that the dignity of the deceased and surviving family is
respected.6 While handling mortal remains of COVID-19 cases, balancing the rights of the
family and infection prevention and control measures is a crucial factor.” – Hal. 1 Introduction

Jadi, krn catatan kematian akibat pandemic ini meningkat, Palang Merah Internasional tuh
mengindikasikan kalo kematian yg disebabkan oleh covid ini bakalan membebani kapasitas local
dalam nanganin jenazah tuh. Jadi perlu persiapan, dan perencanaan yang tepat supaya
menghormati keluarga dan jenazah itu sendiri.

Fundamental principles for the management of death related to COVID-19

“1. The safety and wellbeing of the staff involved in managing the dead from COVID-19 should
be of paramount importance. Hence, implemented protocols should adhere to the advice and
latest recommendations from national health authorities and international health organizations,
particularly the WHO.

2. To ensure the protection and respect for deceased individuals and their families.

3. To establish the reliable identification of the dead, failing which their proper documentation
and traceability are essential for making their future recovery and identification possible.

4. The management of the dead from COVID-19 should not impede the medicolegal
investigation of death whenever required by the authorities.”

– hal. 2 Fundamental principles for the management of death related to COVID-19

Prinsip dasar penanganan kematian: keselamatan dan kesejahteraan staf, harus sesuai
protocol dan mengikuti saran lembaga internasional, terutama WHO; menjamin perlindungan
dan penghormatan jenazah dan keluarganya; untuk identifikasi jenazah yang tepat yang
gagal krn dokumentasi, penelusuran atau tracing yg tepat itu perlu dan penting buat pemulihan
sam aidentifikasi di masa depan; manajemen jenazah/pemulasaraannya ga boleh ngehalangin
pihak FM kalo diperlukan pihak berwenang.

Transmission risk due to handling of bodies with suspected or confirmed COVID-19

“There is no evidence so far of transmission of SARSCoV-2 through the handling of bodies

of deceased persons. Although a case of COVID-19 has been reported in a forensic practitioner
working in Bangkok, capital of Thailand, there is no scientific confirmation of disease
transmission from the corpse. According to the current evidence, COVID-19 virus is
primarily transmitted between people through respiratory droplets and contact routes.

The potential risk of transmission related to the handling of bodies of deceased persons with
suspected or confirmed COVID-19 is considered low, and can be related to:

• direct contact with human remains or bodily fluids where the virus is present.

• direct contact with contaminated fomites.

As studies have suggested that the human coronaviruses can remain infectious on inanimate
surfaces at room temperature for up to 9 days, there is a possibility that the virus also persists on
deceased bodies. Therefore, safety precautions must be adhered to while handling such dead
bodies.” – hal.2 Transmission risk due to handling of bodies with suspected or confirmed
COVID-19

Jadiiii, sejauh ini tuh gaada bukti penularan covid-19 dari orang yang sudah meninggal.
Tapi tuh ada gitu case di Bangkok tim yg nanganin tuh terkena, tapi belum ada bukti ilmiah. Ya
bias aja krn factor lain kan gatau ya, dia ga cuma kontak dengan jenazah kan bisa tuh. Soalnya
menurut bukti sekarang tuh virusnya ditularin lewat droplets pernapasan sama kontak
lainnya.

Ada potensi resiko penularan dalam menangani jenazah yang suspect atau terkonfirmasi,
tapi tuh dianggap rendah, ini dikaitin sama: mungkin ada kontak langsung dengan bekas-bekas
atau sisa dari jenazah ataupun cairan dari jenazah tsb yg mungkin virusnya masi ada. Atau juga
mungkin kontak langsung dengan fomit (benda yg terkontaminasi).

Soalnya dari studi tuh ada yang mengatakan bahwa virusnya bisa menular pada permukaan
bedna mati sampe 9 hari di suhu ruangan. NAH, jadi tuh MUNGKIN krn ini kita tuh perlu
waspada dan prokes pokonya, MUNGKIN ada kemungkinan penularan dari jenazah.

Guidelines on the use of personal protective equipment / APD

“The PPE to be used is based on the risk profile of the healthcare worker. As per the guidelines
issued by the Ministry of Health and Family Welfare, Government of India, dead body handling
in the mortuary is considered to pose a moderate risk; hence wearing an N95 mask and gloves is
recommended. To perform an autopsy, which is a high-risk procedure, it is advisable to wear a
full complement of PPE. For transporting dead bodies, wearing a triple-layer mask and gloves
would suffice. A triple-layer medical mask is a fluidresistant disposable mask protecting the
wearer from droplets of infectious material. An N95 respirator mask is a respiratory protective
device with high filtration efficiency to airborne particles. The filtration capacity of these masks
exceeds those of triple-layer medical masks. As these provide a much tighter air seal than triple-
layer medical masks, they are designed to protect the wearer from inhaling airborne particles.” –
hal 2
APD dipakai tingkatannya sesuai resiko saat menangani, dari Pemerintah India itu mengatakan
kalau penanganan jenazah di kamar mayat: resiko sedang (saran: masker n95 sama gloves);
kalau otopsi: resiko tinggi (saran: APD lengkap)

Pedoman penanganan dan memindahkan jenazah

“All tubes, drains and catheters on the body must be removed. Any puncture holes or wounds
(e.g. resulting from the removal of the catheter, drains, tubes, or otherwise) are disinfected with
1% hypochlorite and dressed with impermeable material. It is essential to plug the oral and nasal
orifices of the body to prevent the leakage of body fluids. If the family of the deceased wishes to
view the body at the time of removal from the isolation room or area, they may be allowed to do
so with the appropriate standard precautions.” – Hal 3 Guidelines for packing and transfer of the
body from the isolation room, ward or other settings to a mortuary, crematorium or burial ground
in non-autopsy cases

Petugas pakai APD sesuai dengan tingkat resiko penularan. Semua alat harus dilepas (alat buat
penanganan misal kyk kateter, tabung, dsb), setiap bekas atau luka missal abis bekas kateter atau
infus atau apapun itu harus desinfeksi dengan hipoklorit 1% terus dibalut sama bahan kedap
air. Penting buat tutup mulut atau hidung buat cegah keluarnya cairan tubuh. Kalau keluarga
jenazah mau melihat? BOLEH. Tapi sesuai SOP yaaa.

“However, as per the guidelines issued by the Ministry of Health and Family Welfare of the
Government of India, the body needs to be placed in a leak-proof plastic body bag. The exterior
of the body bag has to be decontaminated with 1% hypochlorite. The body bag is then wrapped
with a mortuary sheet, or a sheet provided by family members. The body is then either handed
over to the relatives or taken to the mortuary.

If zipped body bags as described are not available, the body can be wrapped in a minimum of
two layers of thick, leak-proof plastic sheets, secured with adhesive tapes.

All used or soiled linen should be put in a bio-hazard bag, and the outer surface of the bag
disinfected with hypochlorite solution. Used equipment should be autoclaved or decontaminated
with disinfectant solutions as per established infection prevention control practices. All medical
waste must be handled and disposed of following biomedical waste management rules.” – Hal 3
Guidelines for packing and transfer of the body from the isolation room, ward or other settings to
a mortuary, crematorium or burial ground in non-autopsy cases

Dari Pemerintahan India tuh bilang kalo jenazah harus diletakan ke plastic tubuh anti bocor.
Bagian luar plastik harus didekontaminasi dengan hipoklorit 1%. Setelah itu plastic/kantong
jenazahanya dilapisi sama kain dari kamar mayat atau yang disediakan keluarga. Setelah itu bisa
diserahkan ke keluarga atau dibawa ke kamar mayat.
Kalo kantong jenazah yg zipper/resleting tuh gaada, bisa dibungkus minial 2 lapis plastik anti
bocor yang tebal, terus dikasi perekat.

Linen bekas atau yang kotor semuanya tuh harus ditaroh di kantong bio-hazard, TETEP
permukaan luar harus dekontaminasi dengan hipoklorit. Untuk alat bekas lainnya harus
dekontaminasi, disterilkan sesuai arahan. Semua limbah harus ditangani terus dibuang sesuai
dengan aturan pengelolaan limbah biomedis.

Guidelines in the context of unidentified bodies infected with COVID-19 – Hal. 4

Intinya di sub bagian ini tuh, petugas wajib pake APD lengkap, soalnya resiko tuh tetep ada
kalo ga terproteksi. Terus buat mayat yang tidak teridentifikasi, sampelnya (sesuai kebutuhan
forensic kyk dna, foto wajah, kuku, dsb) HARUS DISIMPAN buat identifikasi selanjutnya.

Embalming bodies infected with COVID-19 – Hal.4

Di sub bagian ini, sebenernya jenazah dibalsem tuh ga dianjurkan, kenapa? Soalnya buat
ngehindarin kontaminasi terhadap tubuh yang berlebihan. Tapi tuh bisa diakalin pake APD, sama
syaratnya prosedur yg dilakuin harus menghindari supaya ga ngehasilin aerosol.

Environmental cleaning and disinfection – Hal.4

Permukaan lingkungan tempat tubuh terinfeksi dibersihkan dengan sabun dan air atau detergen.
Desinfeksi permukaan pake 0,1% natrium hipoklorit, waktu kontaknya 30 menit, atau etanol 62-
71% yg signifikan mengurangi infektivitas virus dalam waktu paparan semenit. APD harus
lengkap, barang atau limbah ditangani sesuai prosedur.

COVID-19: Funeral guidelines – Hal. 4

Sesuai arahan WHO, jenazah yang meninggal karena covid dapat dikubur atau di kremasi,
sesuai anjuran agama. Namun tidak boleh menyentuh atau mencium, setelah melihat harus
mencuci tangan dengan sabun dan air. Yang menguburkan harus cuci tangan, pakai sarung
tangan, kemudian cuci tangan kembaliuu setelah menguburkan. Untuk masyarakat harus menaati
prokes yang berlaku. Untuk individu yang isoman, atau beresiko tinggi (anak-anak, orang tua,
orang dengan komorbid) sebaiknya tidak menghadiri pemakaman, disarankan virtual.

Psychosocial considerations associated with death due to COVID-19 – Hal. 4

Secara psikologis dampaknya gede banget, apalagi stigma masyarakat yang gatau info
mengenai penyakit ini dengan benar, terus juga jumlah keluarga saat prosesi pemakaman yang
dibatasi, jadi sangat berdampak pada psikologis keluarga yang ditinggalkan.
Repatriation of dead bodies infected with COVID-19 – Hal. 4

Kendaraan angkutan untuk membawa jenazah covid 19 karena memang dibatasi. Ada dua opsi:
dikremasi, atau didalam peti atau tempat yang tertutup rapat. Saat screening (pengecekan
jenazah kalo misal luar kota apa daerah gt) petugas yang screening harus laporan misal kalo ini
ternyata tuh ada kerusakan, bungkusnya gabener, rusak, dsb.

Autopsy in suspected COVID-19 cases

“SARSCoV-2 has been categorized as an HG3 (Hazard group 3) organism. Adequate ventilation
is needed where HG3 autopsies are being performed, with enough separation from the rest of the
mortuary. Natural ventilation with at least 160 l/s/patient airflow or negative pressure rooms with
at least 12 air changes per hour (ACH) and controlled direction of airflow when using
mechanical ventilation is a requirement.25 Whole-room ventilation or down-drafts at work
stations are acceptable, and the following universal precautions in autopsy dissection practice
must be practiced:

Round-ended scissors and PM 40 blades with blunted points should be used to minimize the risk
of prick injuries, and a single practitioner should be operating within the body cavity at any
given time.

• Unfixed organs must be held firm on the table and sliced with a sponge. Care should be taken
to protect the hand.

• An oscillator saw with suction extraction of the bone aerosol into a removable chamber should
be used for sawing the skull; alternatively, a hand saw with a chain-mail glove may be used.

• Needles should not be re-sheathed after fluid sampling. Needles and syringes should be placed
in a sharps bucket.

• It is essential to have all necessary equipment to hand, to avoid the need to leave the area to
find additional items.” Hal. 5

SARSCoV-2 masuk di kategori organisme HG3 (berbahaya/Hazard Group 3). Perlu ventilasi
adekuat wkt dilakukan otopsi. Jarak dengan kamar mayat lain harus cukup. Ventilasi seluruh
ruangan atau down-draft dapat dilakukan, dan tindakan pencegahan berikut harus dipraktikan:

Gunting ujung bundar dengan mata pisau PM 40 dengan ujung tumpul untuk minimalkan resiko
cedera tertentu, dengan waktu tertentu; organ yang ga di fiksasi harus ditahan diatas meja dan
diiris dengan spons, perhatiin prokes yaaaa; untuk menggergaji tengkorak bisa pake gergaji
osilator dengan ekstraksi suction yg bisa dilepasin, kalo ga tuh bisa pakai sarung tangan rantai;
jarum dan spuit tidak boleh re-use, daan diletakan diwadah benda tajam; penting bgt buat cekk
semua alat bahan yg diperlukan untuk prosedur otopsi sebelum mulai, jd ga harus ninggalin
ruangan.
Terus, di sub bagian ini juga dijelasin, perlu mengurangi prosedur yg bisa ngehasilin aerosol,
dianjurin buat pakai perangkat penahan kyk lemari biosafety dll. Kalau otopsi kasus suspect:
specimen post-mortem saran testnya swab nasofaring dan paru. Kalau diagnose covid sebelum
meninggal: mungkin gaperlu lagi, tp sesuai permintaan biasanya sih.

COVID-19 risks from handling the deceased

What we know about COVID-19 transmission – Hal 2

Penularan utama tuh kontak langsung dengan orang yg terinfeksi dan emisi pernapasan
mereka (baik droplet atau aerosol), terus tuh yg kedua itu kontak dengan permukaan ayg
terkontaminasi, terus nyentuh amata, mulut, atau hidung. Transmisi jg bisa terjadi wkt lagi
nanganin pasien covid dengan prosedur yg ngehasilin aerosol.

Kalau dari jenazah, kan gaada tuh emisi aktif pernapasan dari mayat, TAPIIII paparan infeksi tuh
atau transmisi tidak langsung bisa terjadi gara-gara ada kontak gitu sama benda yang
terkontaminasi dengan jumlah virus yg cukup buat menginfeksi kalo kena mata, hidung, atau
mulut; terus juga bisa krn gerakan atau posisi tubuh waktu nanganin atau mindahin jenazah, yg
bisa nyebabin pergesaran rongga pernapasan jd ada kemungkinan lewat emisi udara atau cairan
secara sporadic (ga tentu); terus bisa krn gerakan, manipulasi, atau ada prosedur yg dapat
menimbulkan percikan, semprotan,a tau aerosol cairan tubuh missal wkt otopsi.

“The International Committee of the Red Cross (ICRC) 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.” – Hal. 3
Resiko rendah: kontak langsung saat ke rumah duka, melihat tubuh secara langsung, pelepasan
atau penguburan yg dapat mengakibatkan kontak dengan benda yg terkontaminasi.

Resiko sedang: penanganan manual, seperti membuka pakaian, dsb yang dapat beresiko
menghasilkan tetesan yang tidak disengaja, missal percika cairan saat ke rumah duka dsb.

Resiko tinggi: otopsi dan prosedur invasive lain, pembalseman, penanganan pokonya tuh yg bisa
nyebabin inhalasi langsung tetesan atau aerosol, atau kontak dengan cairan tubuh jenazah
maupun benda yg terkontaminasi.

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? – Hal. 4

Tergantung pada jumlah dan kelangsungan hidup virus dalam paru dan jaringan atau cairan
tubuh lainnya, pada permukaan tubuh atau benda yg terkontaminasi almarhum. RESIKO
TINGGI BANGET wkt penanganan yang SEGERA setelah kematian dengan
APD/prosedurnya tuh ga sesuai. Soalnya tuh patogennya kemungkinan masih hidup tp seiring
berjalan waktu ya berhenti soalnya siklus sel wkt udah meninggal udah berhenti jd virusnya
berkurang.

Persistence of SARS-CoV-2 in bodily tissues and fluids post-mortem – Hal. 4

Jadi emang ada bbrp studi tuh melaporkan RNA Virus SARS-CoV-2 terdeteksi di tubuh
yg udah meninggal, TAPI, adanya virus tuh ga selalu mengindikasikan virusnya tuh masih
bisa menginfeksi. RNA virus tuh terbukti berkurang dari waktu kewaktu, nah waktu virus
UDAH BERHENTI menular pun itutuh masi bisa kedetect, jd tuh ya walaupun kedetect belum
tentu dia beresiko menularkan. HAsil positif tuh menurun dari waktu ke waktu.

Persistence of SARS-CoV-2 on skin – Hal. 5

Dapat bertahan kurleb 9 jam pada kulit pada suhu 25C pada bbrp penelitian, tidak menentu tergantung
specimen yang diambil buat diteliti.

Persistence of SARS-CoV-2 on other surfaces (fomites) – Hal. 5

Beberapaa penelitian menunjukan virus dapat bertahan hingga waktu yang lama