Currently, in the Republic of Korea, post-mortem inspection is conducted at the death scene, emergency room, or morgue. The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during post-mortem inspection of a dead body is relatively lower than that in the case of medical procedures or treatments because dead bodies do not cough and spread droplets. However, an examination of the nostrils and oral cavity is essential during post-mortem inspection. Infectious materials like body fluids can be spilled from nostrils, mouth, and anus of the dead body, and can be existing around it. The house of a dead person and the field at which post-mortem inspection is performed can be contaminated. Furthermore, doctors who perform post-mortem inspections interview the family or the persons who closely contacted the deceased, so the risk of infection surely exists during post-mortem inspection.

Infectivity persists for a certain period after the death of the host in most infectious diseases. For example, HIV-infected bodies should be considered infectious for at least two weeks after death. Hepatitis B virus (HBV) in the environment is also hardy. HBV in human plasma retains infectivity one week after drying and exposure to an ambient environment.1 Post-mortem infection of SARS-CoV-2 has not been reported; however, the exact post-mortem infectivity remains unknown. Furthermore, the stability of SARS-CoV-2 was similar to that of SARS-CoV-1 when tested under experimental conditions. SARS-CoV-2 remained viable in aerosol for three hours. It was more stable on plastic and stainless steel than on cooper and cardboard, with a viability of 72 hours after application to these surfaces. Thus, aerosol and fomite transmission of SARS-CoV-2 is plausible since the virus can remain viable and infectious in aerosol for hours and up to days on surfaces (depending on the inoculum shed).2 Moreover, SARS-CoV-2 can be detected in anal swabs and blood. The number of positive anal swabs was more than the number of positive oropharyngeal swabs in the later stage of the infection, suggesting shedding and thereby transmission through the oral-fecal route.3 The persistence of SARS-CoV, which belongs to the family Coronaviridae, the same as SARS-CoV-2, was observed in feces, urine, and water. In vitro experiments showed that the virus was viable for two days in hospital wastewater, domestic sewage, and dechlorinated tap water, three days in feces, fourteen days in phosphate buffer saline (PBS), and seventeen days in urine at 20°C.4 Middle East respiratory syndrome coronavirus (MERS-CoV) can be detected in the nasal swab of an infected human cadaver (three days following death). In the case of patient death, the deceased should be treated as infectious and as having the ability to transmit the infection.5 The analysis of 22 studies reveals that human coronaviruses such as SARS coronavirus, MERS coronavirus or endemic human coronaviruses can remain viable on inanimate surfaces such as metal, glass, or plastic for up to nine days.6 Therefore, the possibility of infection during post-mortem inspection of a dead person who is suspected to be infected by SARS-CoV-2 should be kept in mind and is important to prevent a post-mortem transmission of SARS-CoV-2 considering the principles for living patients of SARS-CoV-2.

COVID-19 has spread worldwide, and major international organizations and health authorities in developed countries have prepared and reported guidelines for post-mortem examination of dead bodies with a high risk of infection.7891011 However, the post-mortem investigation system differs among countries. The principles and methods of both the clinical approach and post-mortem investigation of COVID-19 are also different among countries. Therefore, it is impossible to accept these guidelines for the Republic of Korea, and these guidelines should be used as a reference. We used both guidelines for living patients of SARS-CoV-2 and international guidelines for the post-mortem investigation of SARS-CoV-2 as references.

In almost all cases of unnatural death, medical history and traces of the past activity are unknown. The doctor is at risk of getting infected while performing a post-mortem inspection. Therefore, post-mortem inspection should be performed under the following basic principles to protect human resources and the local community from post-mortem infection resulting from post-mortem inspection procedures. For all unnatural deaths during an epidemic or a pandemic, a post-mortem caretaker wearing personal protective equipment (PPE) must cover the body following corpse handling guidelines. The external surfaces of the body bag must be sanitized and placed into a second bag for double sealing, and the bodies must be transported to the public morgue, which has safe facilities for protecting the local community from infection. Before post-mortem inspection is performed, infectious diseases must be diagnosed. Post-mortem inspection is performed by professionals according to the result of the diagnosis of infection.

This standard operating procedure distinguishes bodies according to the possibility of infection, considering the current situation in which human resources, systems, and facilities are inadequate in the Republic of Korea. The laboratory test for diagnosis of COVID-19 was conducted according to the decision of the doctor and investigating professionals. However, the following conditions should be fulfilled to protect the post-mortem caretaker and the local community from post-mortem infection; a public morgue which has safe facilities; diagnosis of infection for all unnatural deaths before post-mortem inspection; right to inquire the past medical history of the deceased from the doctor who performs a post-mortem inspection.

If a diagnosed patient dies from COVID-19, it is not subject to post-mortem inspection. However, if it is not possible to determine whether the patient died of COVID-19, or if the patient died from a cause of death other than COVID-19, especially if the death was following the unusual death guidelines published by the Korean Society for Legal Medicine, post-mortem inspection should be carried out. The following are the types of death that require detailed investigation according to the unusual death guidelines of the Korean Society for Legal Medicine:

1) Subject: The deceased who was confirmed according to the diagnostic criteria for COVID-19 (virus isolation and SARS-CoV-2 gene polymerase chain reaction test) regardless of clinical features.

2) Post-mortem inspection should be conducted with minimum manpower, comprising one medical doctor and one member of an investigative agency, and the additional necessary personnel is decided according to the situation.

3) Wear appropriate PPE before entering the site of post-mortem inspection.

4) If necessary, conduct interviews with related persons (family, witnesses, reporters, etc.), and minimize contact with those at risk of infection (call interviews, interviews in separate spaces, interviews after keeping safe distance [more than 2 m]).

5) Perform post-mortem inspection according to standard procedures.

6) After completing the postmortem inspection, the body is packed in a leak-proof plastic bag by specialists, put back into the body bag, followed by sterilization of the body bag surface.12

7) Wastes such as PPEs are disposed off in a previously prepared waste collection bag according to the prescribed procedures (see section 4. Waste management).

8) Fill out and submit the ‘Death (post-mortem inspection) report for infectious patient’.13