Regarding Measures for Actions with a Body of a Deceased Human Who had COVID-19 or Regarding Whom There are Reasonable Suspicions of Having had COVID-19

Issued pursuant to
Sub-paragraph 4.22.⁵ of Cabinet Order No. 103 of 12 March 2020,
Regarding the Declaration of Emergency Situation

Taking into consideration that COVID-19 is mainly transmitted from human to human by droplets of respiratory secretions or by contact upon touching an infected person or surfaces and objects contaminated by the person, and also that the potential risk of becoming infected with COVID-19 upon coming into contact with a body of a deceased human is low, wherewith it is not necessary to conform to all the requirements laid down for the transportation, storage, burial, or cremation of a deceased human if the cause of death of the human is a newly-emerged dangerous infectious disease, and on the basis of the rights specified for the Minister for Health in Sub-paragraph 4.22.⁵ of Cabinet Order No. 103 of 12 March 2020, Regarding the Declaration of Emergency Situation:

1. Upon preparing a body of a deceased human who had COVID-19 or regarding whom there are professionally justified suspicions of having COVID-19 (hereinafter - the body of a deceased human) for burial and upon performing standard, non-invasive last offices, at least the following personal protective equipment shall be used - gloves, a surgical mask, and a long-sleeved water-resistant gown, and also hand hygiene conditions shall be adhered to.

2. Upon performing such postmortem procedures that can lead to splashes (aerosol-generating procedures), in addition to the personal protective equipment referred to in Paragraph 1 of this Order the following personal protective equipment shall also be used - protective goggles or facial shield, and also a respirator (preferably FFP2 or FFP3).

3. Instruments, protective clothing and other materials or objects which have come into contact with the body, tissues, organs, and biological fluids of the body of a deceased human, if they are:

3.1. reusable - shall be disinfected according to the instructions of the manufacturer;

3.2. single use - shall be utilised as dangerous waste.

4. If a person has died at home:

4.1. using gloves, the personal belongings of the person shall be cleaned with a detergent and afterwards disinfected with at least 70 % ethanol solution or 0.5 % sodium hypochlorite solution;

4.2. the clothing of the person and other fabrics, for example, bed linen, shall be washed in a washing machine, using a laundry detergent. The recommended water temperature is 90⁰ C, however, if it is not possible, the clothing and other fabrics shall be washed at a temperature not lower than 60⁰ C;

4.3. the personal hygiene items of the person and other objects (for example, toothbrush, diapers, brush, etc.) which have been used in direct care for the deceased human and cannot be disinfected or their disinfection is not safe or useful shall be considered dangerous waste. They shall be collected separately and, prior to throwing out in a collective waste receptacle, shall be disinfected using agents containing chlorine with concentration of 0.5 % (sodium hypochlorite solution) or inserted in two closed bags and, after seven days, thrown out in a collective waste receptacle.

5. If a person has died at a medical treatment institution:

5.1. personal belongings shall be stored as potentially dangerous in the sense of transmission of an infection and shall be handed over to the relatives with instructions how to perform disinfection or utilisation of the belongings, except for the documents which are necessary for the receipt of burial services - they shall be disinfected and issued to the relatives;

5.2. any single-use medical devices which have been used in direct care for the deceased human, and also personal hygiene items and other objects (for example, toothbrush, diapers, brush, etc.), or medical devices which cannot be disinfected or their disinfection is not safe or useful shall be considered dangerous waste. Such waste shall be processed in accordance with Cabinet Regulation No. 353 of 22 May 2012, Requirements for the Management of Waste Generated in Medical Treatment Institutions. After collection of waste, they shall be placed in a double water-resistant bag (using a bag in a yellow, red, or orange colour as much as possible), sealed up, and labelled as dangerous medical waste from an outbreak of a dangerous infectious disease;

5.3. the environment where the deceased had been stayed shall be cleaned using a neutral detergent followed by disinfection. Such agents of disinfection which are effective against coronaviruses (against enveloped viruses) or 70 % ethanol solution, or 0.5 % sodium hypochlorite solution shall be used;

5.4. persons carrying out maintenance and waste management work shall use the following personal protective equipment - surgical mask, gloves, protective goggles, and gown.

6. The body of a deceased human need not be disinfected, however, it shall be placed in a special bag prior to transportation or placing in a coffin. After placement the bag shall be disinfected from outside.

7. Transportation of the body of a deceased human shall not require special transport equipment or a special vehicle. It can be carried out by any provider of burial services.

8. Persons who prepare the body of a deceased human for transportation (bagging of the body), including also come into contact with the special bag, shall use appropriate personal protective equipment - gloves and long-sleeved water-resistant gown.

9. The pathological-anatomical investigation shall be performed if a person has died:

9.1. with symptoms of a respiratory infectious disease, however, had not been tested for COVID-19 before death or the test result had been negative, and the person corresponds to one of the following risk groups:

9.1.1. has more than 60 years of age;

9.1.2. has chronic diseases (diabetes mellitus, cardiovascular diseases, oncological diseases, etc.);

9.1.3. has suppressed immunity;

9.1.4. is pregnant woman;

9.1.5. is a new-born infant;

9.2. within a month after close (high-risk) contact with a COVID-19 case, and the person had been the contact person of a person infected with COVID-19;

9.3. within two months after contracting COVID-19 that is approved in a laboratory after two negative control tests for COVID-19 had been received;

9.4. in the age up to 17 years (inclusive) with a confirmed COVID-19;

9.5. in pregnancy condition with a confirmed COVID-19.

10. A pathological-anatomical investigation shall be performed at the medical treatment institution where the person died or shall be delivered to the morgue of the pathology unit of the closest medical treatment institution.

11. An autopsy material shall be taken, stored and transported in accordance with Annex 1 to this Order. The form indicated in Annex 2 to this Order shall be used for sending the autopsy material to the National Reference Laboratory in the Field of Epidemiological Safety.

12. The body of a deceased human may be buried or cremated. Burial or cremation shall take place in conformity with the following conditions:

12.1. the coffin shall not be opened during the funeral;

12.2. the personnel ensuring the burial or cremation procedure shall use gloves and shall wash their hands with water and soap after taking off the gloves.

13. The Order shall enter into effect on the day after its publication in the official gazette Latvijas Vēstnesis.

Minister for Health I. Viņķele

Annex 1
Order No. 83
of the Minister for Health

Conditions for the Taking, Storage, and Transportation of Autopsy Material for Laboratory Diagnostics of COVID-19 Infection

The most appropriate autopsy material for laboratory diagnostics of COVID-19 infection is the material from the lower respiratory tract as it contains large quantity of the virus. Together with the material from the lower respiratory tract it is recommended to use also materials from the upper respiratory tract. The method for laboratory testing is the detection of the SARS-CoV-2 virus RNA causing COVID-19 infection using real-time PCR method.

Where COVID-19 infection is suspected, testing of the following autopsy materials is recommended:

lung fragments from the area with damage characteristic to the virus infection;

pleural fluid smears;

postmortem nasopharyngeal swabs.

A lung fragment shall be placed in a sterile vial containing viral transport medium, if it is not available, a vial containing sterile saline shall be used. The specimen shall be stored and transported at a temperature of 2-8^° C within four hours. The specimen shall be transported in a container as hazardous material.

A pleural fluid smear shall be taken using a sterile swab and inserted in a transport medium. The specimen shall be stored at a temperature of 2-8^° C for up to 24 hours. The specimen shall be transported in a container as hazardous material.

A nasopharyngeal swab shall be taken from both nasal passages, after taking of the swab it shall be placed in a viral transport medium. The specimen shall be stored and transported at a temperature of 2-8^° C within 24 hours. The specimen shall be transported in a container as hazardous material.

The transportation time shall only apply to the material to be tested. The period between the time of death and the pathological-anatomical investigation of the body of the deceased human shall not apply to the material to be tested!

Special stabilising medium for viruses and their RNA/DNA - commercial ones or prepared at the National Reference Laboratory in the Field of Epidemiological Safety - shall be used for the transportation of specimens:

1. media must be ordered in a timely manner, sending the orders in free form to the e-mail: dzintra.salmina@aslimnica.lv or gatis.pakarna@aslimnica.lv;

2. before delivery of the specimens to the National Reference Laboratory in the Field of Epidemiological Safety, a notification of the planned delivery of specimens must be made by phone using the twenty-four-hour line: 29114493 (in case of uncertainties telephone lines 67014775 or 67014215 may be used on working days from 08.00 to 16.30).

The specimens must be delivered to the National Reference Laboratory in the Field of Epidemiological Safety at the specimen acceptance, registration, and logistics unit (Linezera iela 3, Riga) at any hour (24/7).

Attention! The biosecurity requirements must be strictly followed during the course of work!

Annex 2
Order No. 83
of the Minister for Health

Referral to the Testing of Autopsy Material for the Diagnostics and Differential Diagnosis of COVID-19 Infection

National Reference Laboratory in the Field of Epidemiological Safety, Linezera iela 3, Riga, LV-1006, Latvia

(tel.: 29114493; 67014215; 67014775)

Identification of the patient: Given name, surname Personal identity number Age Sex f m Place of residence (city or municipality, parish, street, house No.) Medical card No. Diagnosis Date of contracting the illness Information regarding connection with an outbreak of epidemic	Identification of the commissioning party: OUTPATIENT  INPATIENT  PAID  NHS
	Medical treatment institution Code of the institution Address Unit Physician (given name, surname, personal identity number)   (speciality code, telephone number) Date, time of taking the material to be tested Sending date Sender Number of analyses sent	Notes of the physician (if necessary): Date of death Time of death Other information Reason of testing: LP4 (testing of a material obtained during surgeries or manipulations)

Lung autopsy material		Pleural fluid smears	Postmortem nasopharyngeal swab
	SARS-CoV-2 RNA (Coronavirus nCoV-19 RNA)
	Multiplex RNA/DNA RV16 Parainfluenza virus 1-3, Adenovirus A/B/C/D/E, Coronavirus 229E/NL63, Coronavirus OC43, Rhinovirus A/B/C, Influenza A virus, Respiratory syncytial virus A, Respiratory syncytial virus Bocavirus 1/2/3/4, Influenza B virus, Metapneumovirus, Parainfluenza virus 4, Enterovirus
	A/B type influenza RNA quality

The autopsy material shall be taken not later than 24 h after death, transported in a sterile vessel with a transport medium (may be received at the Sample Acceptance Unit of the inpatient hospital Latvian Infectology Centre of the Riga East University Hospital, Linezera iela 3) Lung material fragment ~ 0.5-2 cm³.

Translation © 2020 Valsts valodas centrs (State Language Centre)