As COVID-19 cases spread across the nation, disrupting daily routines for the living, growing numbers of U.S. businesses and families are changing how they deal with the dead.
Funeral homes — already well-versed in ways to prevent disease — are implementing even stricter protocols to handle bodies infected with the novel coronavirus.
Families of people who die from any cause, not just COVID-19, are being asked to scale back how they memorialize their loved ones by changing or postponing funeral services, limiting the number of people who can attend and increasingly using online tools.
"The overwhelming majority of families understand," said Matt Levinson, president of a Maryland funeral home that is limiting private graveside services to 10 people or fewer to comply with federal guidelines. "They're not happy about it, but they understand that safety is more important."
More than 7,700 cases of COVID-19 have been confirmed in the U.S., and more than 115 deaths, although infectious-disease experts say those figures are likely vast undercounts.
In Washington state, where more than 1,100 people have been infected by the virus and more than 65 have died from the disease, funeral homes in the Seattle area and beyond are bracing for more bodies.
"Once the medical system gets overwhelmed, who's next?" said Sandra Walker, president of the Washington Cemetery, Cremation and Funeral Association. "That would be us."
Across the U.S., about 7,800 people die each day from any cause, a number that is only expected to increase. It's impossible to predict how many people will die from COVID-19 disease, with U.S. estimates ranging from tens of thousands to more than 2 million in a worst-case scenario.
That's expected to fuel a grim rise in business for mortuaries and crematoriums, said Barbara Kemmis, executive director of the Cremation Association of North America. Nearly 55% of people in the U.S. opt for cremation, with about 40% choosing traditional burials.
"We've come out of the flu season and, for much of the U.S., the winter weather, where death rates are usually higher," Kemmis said. "What a lot of funeral businesses are preparing for now is no slowdown."
Federal government guidelines banning gatherings of more than 10 people, plus state and local directives ordering residents to shelter in place, will curtail all but the most basic rituals.
In Washington, D.C., Arlington National Cemetery is closed to the general public to stem the spread of infection. Though funerals can still be held there, at least three dozen have been postponed in the past week, said Barbara Lewandrowski, the site's director of public affairs.
"Each individual family has a personal reason for waiting," she said.
Jack Mitchell, a spokesman for the National Funeral Directors Association and director of a Baltimore funeral home, had a service scheduled for Thursday at a local retirement center. Amid coronavirus concerns, the center abruptly canceled the reception and post-cremation burial ceremony.
"I'm going to hold the urn and they'll have the service at a later time," Mitchell said.
As funeral workers handle more bodies potentially infected with the COVID-19 virus, they're doubling down on their usual precautions to avoid disease, said Rob Goff, executive director of the Washington State Funeral Directors Association.
"We're not sure how long the virus will last on deceased human tissue at this point," he said.
Workers transporting bodies are advised by health officials to place masks over the mouths and noses of those who have died because bodies can exhale the virus when moved. Workers also should use double body bags to contain them, Goff said. Guidelines from the Centers for Disease Control and Prevention call for disinfecting the outside of body bags and following embalming precautions for hard-to-kill viruses.
Funeral homes are discouraging touching or kissing the bodies of people who have died of COVID-19, said Bob Achermann, executive director of the California Funeral Directors Association.
"Those cultures where you may have different customs, such as bathing the body or a shroud, you may think about whether that's advisable when COVID-19 was the diagnosis," he said.
More funerals — and the arrangements for them — are being conducted online, Achermann added, to protect staff, families and guests from potential infections.
As a result, demand is surging for virtual funeral webcasts and other online services. Funeral-related websites, including eCondolence.com and shiva.com, have seen a "tremendous increase" in online traffic, said Michael Schimmel, chief executive of Sympathy Brands, an online marketplace.
"People just want to make sure they do the right thing," he said.
David Lutterman, the chief executive of OneRoom, an international firm that has specialized in livestreaming funerals for the past decade, said the company's 100,000 weekly views have spiked about 60%.
"It's almost like the ability to stream a service has suddenly become the most important thing a funeral home can do," said Lutterman.
Still, the crisis is difficult for families who may not be able to mourn in their usual way. At the Sol Levinson & Bros. funeral home in Pikesville, Maryland, staff members are advising Jewish clientele to forgo the traditional sitting shiva ritual that invites mourners to gather at the family's home, Levinson said.
In Hayward, California, where a shelter-in-place order is in effect, in-person viewings continue at Chapel of the Chimes, a 61-acre cemetery and funeral home complex. But visitors there are being asked to stagger their arrivals to keep groups smaller than 10, and to follow social-distancing and hygiene guidelines.
"Our families are being incredibly gracious," said General Manager David Madden, noting that funeral homes are considered essential businesses that can remain open.
Many funeral directors in Washington state are limiting the number of family members allowed in waiting rooms and offices, or they're conducting business using email, remote document signing and other electronic tools. That means less in-person support for families.
"Typically, when people are grieving, they like to console each other," Walker said. "It's already a tough time for families, and this kind of compounds their grief."
Walker and others are watching closely as public health experts work to slow-growing numbers of COVID-19 cases. She's seen the frightening reports from Italy, where traditional funerals have been outlawed and bodies are piling up in hospital morgues.
She wouldn't speculate about whether that scenario could happen in the U.S.
"I don't want to say we're going to be Italy," she said. "I just think we have to do one day at a time. I told my team today, It might be one hour at a time."
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.