Introduction

In Malaysia, certain infectious diseases are classified as high-risk, falling under Hazard Group 3 and Hazard Group 4 categories. The Hazard Group 3 category includes serious diseases like COVID-19, Tuberculosis, Human Immunodeficiency Virus (HIV), Hepatitis B, and Hepatitis C, while the Hazard Group 4 category encompasses highly dangerous diseases like Ebola, Marburg, Nipah Virus, Lassa, and Congo-Crimea Haemorrhagic Fever, for which effective treatments are often unavailable.

Hazard Group 3 and 4 cases are considered high-risk biohazard cases for mortuary management. This categorization is based on the potential for serious effects on individuals and the risk of spreading to the community. However, please note that classifications and guidelines for infectious diseases may be subject to updates and changes by health authorities, and it’s essential to refer to the most recent information from the Ministry of Health Malaysia or other relevant health authorities for the latest classification of COVID-19 and related guidelines.

It is crucial to understand how to handle infectious bodies in high-risk cases like COVID-19, as it poses a significant threat to public health. Proper safety measures are essential in managing such cases to protect healthcare personnel and the public from potential transmission.

Receiving Dead Body from the Hospital Ward

The ward staff has the responsibility of notifying the mortuary in cases of suspected, probable, or confirmed high-risk biohazard cases. Additionally, they must attach biohazard tags to the bodies of all individuals falling under this category. It is essential to properly cover any open wounds on the deceased during the last office procedure.

Medical personnel involved in transferring deceased bodies are advised not to smoke, eat, or drink during the process, and they should avoid touching their mouth, eyes, or nose. Adherence to the minimum PPE requirement is mandatory for all medical personnel to minimize the risk of exposure.

Furthermore, any spillage from the body bag should be strictly avoided until proper decontamination can be carried out in the mortuary. In cases involving suspected, probable, or confirmed high-risk syndromic biohazard cases and Hazard Group 4 cases, additional requirements are applicable. The body must be prepared in the ward with multiple layers, including white linen and double body bags.

To ensure proper biohazard control and disinfection, it is essential to thoroughly disinfect the body bag, particularly focusing on and around the zipper area, using a suitable disinfectant such as 0.5% sodium hypochlorite. This step is crucial in preventing the potential spread of infectious agents and maintaining a safe environment for handling deceased individuals.

Medical personnel involved in transferring the body in such cases should wear double gloves, a long-sleeved plastic apron, and an N95 mask as part of their PPE. Additionally, trolleys used for transporting these bodies must be disinfected using appropriate disinfectant after each use to prevent potential contamination. To further reduce the risk of infection, all equipment used for transportation should be decontaminated using chlorine solution and sodium hypochlorite 70%.

Receiving Dead Body from Outside Hospital Facility (Brought in Dead [BID] Case)

To ensure proper handling and safety protocols, it is imperative not to open sealed body bags received from the police in the mortuary without further instructions from the medical officers or Forensic Pathologists. These instructions are crucial to prevent any potential risks or contamination.

The handling and management process for receiving infectious bodies from external hospital facilities are the same as the procedures followed when receiving bodies from hospital wards.

Storage of Body

It is recommended that all biohazard cases be promptly stored in dedicated body refrigerators upon receipt at the mortuary. However, exceptions may be made if no autopsy is required, and the body can be released to the claimant within the specified time as per the standard operating procedure (SOP).

To ensure identification and safety, all stored suspected or confirmed biohazard cases must have biohazard tags attached to the refrigerator doors. Personnel involved in handling the bodies are required to follow standard precautions and wear protective clothing, including a surgical mask, gloves, plastic apron, and boots.

Upon receiving a body, the mortuary personnel are responsible for registering the body, verifying its identification, and labeling it with appropriate biohazard and freezer labels. These labels carry identical information to facilitate easy identification of bodies in their respective body freezers.

In cases where immediate claimant parties are available, the body may be released as soon as possible, and the Public Health Inspector supervises the body release. However, for bodies without claimant parties, the mortuary personnel must verify the body tag and labels the respective body freezer before storage.

Before storing the body, the mortuary personnel ensures that the body freezer is in proper working condition. These measures are crucial in maintaining the integrity of biohazard cases and ensuring the safety of mortuary personnel and the public.

Post-Mortem Examination of Body

Post-mortem examination for high-risk cases will only be conducted if Borang Permintaan Pemeriksaan Mayat, Polis 61 Pindaan 4/68 (Appendix 10) is obtained.

It is strongly advised against performing autopsies of suspected or confirmed Hazard Group 3 cases in mortuaries that do not meet minimum building standards and lack proper ventilation and suitable personal protective equipment (PPE). Autopsies of cases related to Hazard Group 3 syndromic outbreaks like SARS should only be done in Biosafety Level-3 (BSL-3) mortuaries, categorizing them as high-risk syndromic biohazard cases.

Autopsies of suspected or confirmed Hazard Group 4 infections should not be conducted in mortuaries without Biosafety Level-4 (BSL-4) facilities, which are currently not available in Malaysia.

Post-mortem examinations on cases with unknown pathogens, should only be conducted by a senior pathologist in a Biosafety Level-2 (BSL-2) plus or BSL-3 autopsy room. This facility has special features such as separate entrance and exit areas, a separate ventilation system with negative pressure rooms, separate clinical waste management, and drainage systems, as well as a decontamination space for the involved personnel.

Before conducting autopsies, a pre-autopsy risk assessment is crucial to determine the need for additional safety precautions and suitable mortuary facilities. Proper PPE and safety equipment are fundamental for a safe autopsy. It is importance to comply with safety measures even if pre-autopsy screening for blood-borne viruses returns non-reactive results. Following these safety measures helps ensure the well-being of the individuals involved and minimizes the risk of exposure to hazardous materials during the autopsy procedure.

For high-risk non-syndromic biohazard cases, such as Hepatitis C, HIV, and tuberculosis, specific PPE is required, including surgical scrub suits, waterproof disposal gowns, N95 masks, eye-visor/goggles, disposable head caps, anti-static rubber boots or waterproof boots, and double gloves.

Staff working in the post-mortem examination room during high-risk cases should receive adequate training in mortuary techniques and safety procedures. The examination will be carried out by the senior forensic pathologist and assisted by two health personnel. To minimize the risk of infection, there should be a minimal number of personnel (not more than 3 people) involved in the examination procedure.

After completing the autopsy, proper disposal of used PPE and strict adherence to hand hygiene procedures are essential. The instruments and facility should be cleaned and disinfected. Waste products, including disposable protective clothing, will be marked as high-risk waste and managed separately from regular clinical waste. The body is stored in a double body bag, sealed, and marked as a biohazard body within the freezer.

Handling of Post-Mortem Specimen Collection

The pathologist determines the need for a specimen and whether it is a medicolegal case. If not, the specimen is collected and sent for testing through the respective laboratories. In the case of medicolegal cases, the sealed and labelled specimen is handed over to the police, with an acknowledgment receipt stored as per MOH procedure. The police are responsible for sending medicolegal specimens to the respective laboratories.

All biological specimens obtained during autopsies are considered biohazard materials and should be treated accordingly. Autopsy tissues and body fluid specimens intended for pathological and toxicological analyses should be collected in prescribed containers and treated as biohazard materials.

A few examples of clinical specimens collected include cerebrospinal fluid, conjunctiva swabs, throat swabs, pleural fluid, and others. The most common medico-legal specimens collected are blood and urine specimens for toxicology analysis.

The process begins with sampling and placing the sample in a leakproof primary container, which serves as the first layer of packaging. The container’s cover is sealed with two layers of parafilm to ensure proper closure. To further enhance safety, the specimen container is sprayed with a 10% sodium hypochlorite disinfectant.

Next, the sample container is placed in another container or biohazard plastic bag, acting as the second layer of packaging. Subsequently, the specimen container is transferred to a multipurpose container which serves as the third layer of packaging. The outer layer of this container is disinfected using universal wipes or disinfectant spray.

For transportation, the specimen container is placed in a polystyrene box containing an ice pack to maintain proper temperature conditions. The box’s cover is sealed with tape to secure the contents. The box is labeled with a clear indication of being a BIOHAZARD specimen for easy identification.

Lastly, the outer layer of the shipping box is disinfected using universal wipes or disinfectant spray before sending the specimen to the respective laboratories. To ensure safe shipping, the secondary packaging should be a leakproof and watertight container with absorbent material, while the tertiary or outer shipping box should be rigid to protect the specimen during transportation.

It is important to avoid excessive packaging, which could make unpacking difficult. Following these systematic procedures ensures the safe handling and transportation of biohazard specimens to laboratories for further analysis.

Release of Body

Body release from the mortuary is a crucial process that involves careful checks and adherence to approved procedures and policies. The mortuary personnel must first confirm whether the claimant party is present and ready to claim the body. If the claimant is available, the mortuary personnel proceeds with the release process in accordance with the established guidelines and policies.

The body release should take place in the body preparation room rather than directly from the storage area. This is to ensure proper handling and compliance with infection control measures to safeguard both the mortuary staff and the claimant party. By conducting the release in the designated preparation room, any necessary precautions and protective measures can be implemented effectively.

However, it is essential to discourage bathing rituals or mandi kafan by relatives before body release. In the case that the body requires mandi kafan prior to leaving the mortuary, the participants involved must be adequately counseled by the mortuary personnel or the Assistant Environmental Health Officer regarding the potential risks of infection. If necessary, they should don proper personal protective equipment (PPE) during the rite to minimize any risk of transmission.

For specific high-risk cases, such as HIV or Hazard Group 4 cases, additional precautions must be taken during body release. Such cases require strict adherence to precautionary measures and should be supervised by an Assistant Environmental Health Officer to ensure proper handling and safety.

In instances where religious last rites or rituals are to be conducted, the mortuary staff should be mindful of infection control protocols. For Muslim bodies undergoing mandi kafan, only fully vaccinated trained individuals should be involved in handling the procedure, and they must wear appropriate PPE, including an N95 mask, gloves, face shield, and a long-sleeve water-resistant gown. Fully vaccinated family members or relatives may be allowed to observe and assist with strict compliance to PPE and safety instructions, subject to the nature of the case and risk level.

Similarly, for non-Muslim bodies undergoing religious last rites/rituals, the handling should be kept to a minimum, and individuals involved must wear proper PPE, including an N95 mask, gloves, face shield, scrub suit, and a long-sleeve water-resistant gown. Embalming should be avoided.

Once the religious rituals are completed, the body bag should be zipped or sealed, and the outer layer of the body bag disinfected with 0.5% sodium hypochlorite to ensure proper decontamination.

Burial or Cremation of Bodies

The guidelines for the burial or cremation of high-risk bodies are important to minimize the risk of transmission during handling and disposal. Direct contact with the body is discouraged, and relatives are strongly advised not to touch or kiss the body. If unavoidable handling is necessary, full precautionary measures and appropriate personal protective equipment (PPE) must be worn by relatives or undertakers.

The bodies should be promptly taken for burial or cremation directly from the mortuary. For non-Muslim bodies, they may be placed in coffins with an airtight sealed glass cover, allowing for viewing of the face while maintaining precautions. However, family members are prohibited from opening the sealed coffin or body bag to minimize any potential risks. Trained personnel, supervised by an Assistant Environmental Health Officer, should conduct the burial or cremation process with strict adherence to SOP and appropriate PPE.

Deaths occurring in private hospitals should follow the same burial or cremation procedures outlined above. The body is to be released for burial or cremation directly from the private hospital, where it will be placed in a plastic bag and then sealed in a coffin before being transported to the burial or cremation site.

Handling of Unclaimed Body

If there are no claimant parties available to claim the body, the mortuary personnel will store the body following approved policies. The mortuary personnel will also assist the police in general identification of the body and arrange for a press release.

For Muslim bodies not claimed within 3 days, they will be classified as unclaimed and referred to the Islamic Religious Body for burial purposes. Similarly, non-Muslim bodies not claimed within 3 days will be classified as unclaimed and referred to the respective religious body or welfare organization for burial or cremation. The Hospital Director will sign a referral letter to the respective religious body/welfare organization after obtaining clearance from the police.

Reminders will be sent to the respective religious body or welfare organization at predetermined intervals as defined in the local operational policy. If after 2 weeks, the criteria for claiming the body are not fulfilled, the Hospital Director will authorize a hospital burial.

Upon collection of the unclaimed body by the authorized representative of the respective religious body or welfare organization, the mortuary will issue the burial permit and release the body according to the stipulated guidelines. The procedures ensure proper handling and disposal of unclaimed bodies while adhering to local policies.

Transportation of Body to the Other Country

The transportation of high-risk bodies, including COVID-19 cases, to other states or countries will be managed according to the Garis Panduan Pengimportan atau Pengeksportan Mayat Atau Mana-mana Bahagiannya, Edisi Kedua, subject to the Prevention and Control of Infectious Diseases Act 1988, Act 342, which states that anyone who wishes to import or export any human remains, human tissue, or any part thereof into or out of Malaysia requires the permission of an Authorized Officer.

An Authorized Officer can be any Health Officer, Health Inspector, or officer appointed by the Minister under Section 3 of the Prevention and Control of Infectious Diseases Act 1988.

The legitimate heirs/representatives of legitimate heirs are required to make an application and obtain permission from the Authorized Officer to send the body to the desired location. The application for the import or export of human remains must comply with the regulations, guidelines, and other conditions stipulated in the guidelines.

Applications for Import/Export of Human Remain Permit can be made online through the BLESS system (www.bless.gov.my). The permit will only be issued if the following documents are complete:

Each permit application is limited to one (1) imported or exported body only. This permit will only be issued for Malaysian citizens’ bodies.

High-risk bodies should first be placed in a body bag before being transferred to a special coffin. For transportation purposes, the coffin used must be a wooden coffin with a zinc inner box.

References