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May 21, 2020 -- As the coronavirus death toll has risen around the world, it has created an unprecedented challenge for the healthcare workers, forensics experts, and funeral directors who manage the bodies.
The dead piled up in the streets of Ecuador. In New York City, hospitals ran out of morgue space, so volunteers piled corpses into refrigerated FEMA trucks instead. Traditional funeral practices have been upended around the world, as governments have worked to reduce the chance of transmission between the living. And millions are grieving in isolation.
But some of the most fundamental mysteries about corpse management — like how long after death the SARS-CoV-2 virus can stay active — remain unanswered. "I've asked that question probably 10 times and nobody's really given me a good answer yet," Bob Lawler of the Lawler and Crosby Funeral Home commented in a recent radio interview.
That's because the scientific literature on the post-mortem risks of the coronavirus is almost nonexistent, said Angelique Corthals, a professor of pathology at CUNY's John Jay College of Criminal Justice in New York City. Researchers have rightly prioritized investigation of lifesaving interventions. But even when opportunities for post-mortem insights arise, they're often neglected. A recent German pre-print study, for example, used a corpse model to assess the risk of COVID-19 transmission during CPR, but gathered no additional data on the risks posed by the dead.
"That's the problem with dead bodies," Corthals said. "Out of sight, out of mind."
While the US Centers for Disease Control and Prevention, the World Health Organization, and other agencies issued interim guidelines for interacting with COVID-19-infected bodies, their advice is based on a mixture of common sense and past experiences with other infectious diseases, not COVID-19-specific research. That's why the advice sometimes differs (the CDC, for example, is supportive of continued embalming, whereas the WHO urged caution).
On the whole, "the greatest risk is from the living and not the dead," said Oran Finegan, head of forensics for the International Committee of the Red Cross (ICRC). Whereas the living can move around — shedding a virus — as soon as someone's cells begin to decompose, any viruses living inside also start to decay.
How fast this process occurs depends on where the virus lives — and how quickly autolysis occurs in those systems. "For some viruses, it's a matter of hours after the death of the host," Corthals said. Hepatitis, for example, exists mainly in the liver, which undergoes rapid autolysis, quickly rendering the body noninfectious.
But the decomposition process "goes both ways," Corthals said. When someone dies, their immune system stops working. "The [viruses] lose their house, but they don't have the army waiting outside." That can mean, at least for a time, that a virus is able to multiply in a corpse, before factors like autolysis ultimately eliminate the risk.
For SARS-CoV-2, we don't know where the virus is," Corthals said, with the pathogen turning up everywhere from nasopharyngeal swabs and lung tissue to ocular fluid and feces. But narrowing that down could lead to valuable insights into how long it poses a risk after its host dies.
Additionally, the post-mortem research on the coronavirus that does exist isn't as air-tight as it may seem. "One of the problems that I've seen in a lot of the scientific literature is that there hasn't been a clear demarcation between detection" of an active vs an inactive virus, Corthals said. Studies looking at how long the novel coronavirus can survive on surfaces have relied on RT-PCR, which can detect minute quantities of the pathogen. That sensitivity is useful in other contexts, like patient diagnostics, but it doesn't actually indicate if the virus is still virulent. To determine that, scientists would have to take the extra step of infecting a cell with the viral components they identified and waiting to see if it replicates.
Unfounded conclusions are especially concerning in this context, because studies on death and dying can quickly catch fire with the public. In April, a letter to the editor of the Journal of Forensic and Legal Medicine claimed to be the "first report of COVID-19 infection and death among medical personnel in a forensic medicine unit." Ten days later, the journal published a correction: no one had died, and there was no evidence of corpse transmission. "The authors do not know for sure and cannot scientifically confirm that the virus moved from the dead body," wrote the authors in the correction. But by then, news outlets around the world had already jumped on the story.
In the absence of substantial evidence on SARS-Cov-2, funeral directors are holding fast to universal precautions. "Funeral directors are trained when they're in mortuary college that you treat every deceased individual as if they're contagious and you never let your guard down," said Gene Allen, president of the Texas Funeral Directors Association. "Does that mean everybody does? No. But in this situation, it's caused a lot of folks that typically don't take it seriously to rethink and do what they trained to do."
In addition to donning personal protective equipment, morticians keep corpses in plastic body bags between preparation and burial or cremation, and regularly sanitize the exterior. Sometimes, the dead are masked, too: when corpses are moved, the lungs can exhale, potentially spreading the virus in the process.
"We are doing what we need to do to make sure everyone stays safe regardless," said Patrick Schoen, a managing partner at Jacob Schoen & Son in New Orleans. But the implications of the pandemic stretch far beyond nitrile gloves.
"It's changed everything for us," said Schoen, a fifth-generation funeral director. His team has minimized the number of workers assigned to a given task, such as embalming. They've stocked up on N95 respirators, many of them gifts from the community. And most funeral arrangements are now being made over the phone. To further encourage distancing, the state of Louisiana even changed its laws to allow cremation directives to be signed online, with DocuSign. (Before the change went into effect, Schoen said his staff would place paper directives in Ziploc bags on a family's driveway, wait for them to sign it, disinfect the bag with Lysol, and wait a few hours before removing the paper inside for processing.)
These precautions are clearly working; funeral directors don't appear to be getting infected or dying of the coronavirus at alarming rates like many other frontline workers. But maintaining this level of caution may be difficult. Just as the shortage of PPE has affected first responders across the country, morticians from Texas to Massachusetts to Ohio have also faced dwindling supplies.
Not only do these "last responders" need the equipment for preparations, but Schoen said funeral directors have also had to give gloves and masks to families making arrangements or attending services. In many cases, the state has had to step in to help. In Oklahoma, the governor gave morticians access to the state's stockpile. In Texas, funeral directors were narrowly spared by an influx of FEMA supplies, Allen said.
"Ultimately, we need to ensure the protection and dignity of the dead in these types of situations," Finegan, head of forensics at ICRC, said. But the safety of the people who provide these services must be ensured, too.
Going forward, Corthals said there are countless questions to investigate. But she hopes researchers will narrow in on two of the most important — where the virus lives in the body, and how long it can survive after death — sooner than later. Without it, the "deathcare" sector will still be fighting blind.