Last Rituals and handling of deceased in corona pandemic

Arif Rasheed Malik1, Maha Kamran2.

  1. Chairman, Forensic Medicine and Toxicology, King Edward Medical University, Lahore.
  2. Student, 3rd year MBBS, King Edward Medical University, Lahore.

Corresponding Author: Arif Rasheed Malik, Department of Forensic Medicine and Toxicology, King Edward Medical University, Lahore. Contact Author.

Publication: May 11, 2020.

© Author(s) (or their employer(s) 2020. Re-use permitted under CC BY. No commercial re-use. Published by Pak J Surg Med. 

Article Citation: Malik AR, Kamran M. Last Rituals and handling of deceased in corona pandemic. Pak J Surg Med. 2020;1(2):91-93. doi: 10.37978/pjsm.v1i2.129

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Lonely death and no relation at last rights, This may seem like the ending of an incredibly sad film, but unfortunately, it has become the reality of people infected by the presently-pandemic microbe, the Coronavirus; specifically a novel strain of it, the COVID-19 virus.[1] COVID-19 is one strain that wasn’t previously identified in humans. It first showed signs of its existence in late 2019 in Wuhan, China, where the reported case of the individual developed a mysterious illness, that proceeded to show worsening signs of the acute respiratory disease started.[2] From there, in just a matter of months, it has caused a large and ongoing outbreak. Since then, there have been thousands of confirmed cases and alarmingly increasing deaths worldwide. Recent evidence suggests that it is transmitted between people through droplets, fomites, and close contact, with possible spread also through secretions and feces.[3] This is a new virus whose source and disease progression are not yet entirely clear, hence more precautionary measures are a necessity until more and definite evidence is available about its mode of progression.

Ever since the first person passed away from this utterly infectious malady, it became quite clear that the proper last rituals of the suspected or confirmed case of COVID-19 were an urgent necessity, with each situation to be managed on a case-by-case basis, balancing the rights of the family, the need to investigate the cause of death, and the risks of exposure to infection.

Hence, an efficient protocol of dealing with the infected corpses has to be devised as a national action plan to combat the risks involved during the transportation, handling and if needed, postmortem examination of the dead body. A separate set of guidelines for the systemic burial of the departed soul should also be set forth to assure the maximum limitation of the spread of the disease while maintaining the dignity of the deceased.

Considering the contiguity of this virus, it only makes sense that the health care workers and all other associated personnel such as, funeral directors and mortuary staff, in close contact with the corpse be given utmost priority. The safety and well being of all the handlers ought to be ensured by providing all, necessary resources for keeping them out of harm’s way, which includes both structural equipment like PPEs (i.e. gloves, gowns, face shields, N95 masks, goggles, shoe covers, etc.), sanitizers, clean autopsy tables, and working environment. Also, comprehensive instructions to follow, allowing minimum fanning out of the infection to healthy individuals including themselves, which may include providing training in hand hygiene and how to put on / remove PPEs.

Hence after the death of the patient, the first and foremost thing is the complete protection of the staff, ensuring all protective precautions. After covering yourself up according to the extent of the task at hand, the body is to be wrapped “up in a cloth” and transferred to a mortuary ASAP, while ensuring all orifices are closed and bodily fluids are contained. In accordance to WHO guidelines, cadavers lack the ability to spread infections; however, as reported by an authentic news source, Thailand had allegedly the first fatal case of the infection transmitted from a dead patient to a medical examiner, a finding that added to the safety concerns for morgue and funeral home workers amid the global pandemic.[4] 

“It is more resilient in that it sticks around the dead body,” says California’s Dr. Judy Melinek, bringing forth another warning sign for forensic pathologists dealing with the malady in their laboratories. “[COVID-19] is a respiratory pathogen and can be transmitted via respiratory droplets, but also through the blood of a viremic patient. Even though decedents don’t cough, they can expel bodily fluids while they are being moved or transported, “she explained.[5]

Hence some additional precautions to be taken into account while managing an infected dead body’s transport to a mortuary include;

  • Avoiding unnecessary manipulation of the body that may expel gas from the lungs.
  • Ensure all orifices of the body are plugged and handler is covered enough to avoid any splattering.
  • Prepare the body for transfer including removal of all lines, catheters, and other tubes.
  • Adults >60 years and immunosuppressed individuals should not directly interact with the body.
  • Allow the family to view or touch the body only following strict precautionary measures, including washing hands before and after.

When the body arrives in a morgue, the decision to perform an autopsy is made. In areas where there is a known pandemic, the autopsy is not required in patients with diagnosed COVID infections, and a mere chest X-ray, extraction of a Nasopharyngeal swab specimen and the patient’s complete history is enough to deduce whether the patient has died of corona or not.[6] However, in cases where a John Doe or a Jane Doe is brought over by the police, a postmortem is done to confirm the cause of death and that may turn out to be a neglected case of the virus outbreak.

Hence, even the police handling such bodies in an open pandemic area, ought to take the same precautionary measure, as health care providers. Proper gloves, face mask and performing hand hygiene as they return home after a long day’s work, is thus, just as important for the Law Enforcement Agencies (LEA), as for health care providers. Especially, since they’d be dealing with more people every day similar to doctors and this may resort to playing a role in spreading the infection. Unfortunately, neglect has caused infection among the brave officers of LEAs involved; one such example would be of a 38-year-old civilian dispatcher policeman of the Detroit Police Department dying of COVID-19. After which 282 policemen self-quarantined.[7]

Moving on, let’s address the morgue situation and environmental control measures necessary if an autopsy has to be performed. Important initiatives are:

  • Embalming the dead body is not to be allowed.
  • The autopsy room and all its contents must be sanitized thoroughly with 1% Sodium hypochlorite.
  • Only a minimum number of staff ought to be present in the autopsy room.
  • Staff must make use of the PPEs available and be well-trained in infection prevention control practices.
  • Autopsy procedure should be carried out keeping in view the measures considered during routine P/M procedures (i.e. must be a well-lit room, with enough ventilation, etc.)
  • Reduce aerosol generation during autopsy using appropriate techniques especially while handling lung tissue.
  • Negative pressure to be maintained in the mortuary.
  • Round ended scissors should be used.
  • At the end of the procedure, the body should be disinfected with 1% Sodium Hypochlorite and placed in a body bag, the exterior of which will again be decontaminated with the same solution.
  • Thereafter the body can be handed over to the relatives.

The relatives can then perform their burial rituals, as desired. Some families may prefer handing the body over to funeral directors so that the standard precautionary measures can easily be brought to action and proper arrangements are made. It is significant to note in some cultural institutes of specific societies, cremation is preferred over the burial ritual. Some sources believe that the perfect route to disposal of infected vessels is cremation, as it completely rids of the entire body by burning its entirety to ashes. Still, other religions accept a proper burial as the only way of ‘resting in peace’, their deceased. This decision requires consideration of the religious and cultural perspectives of the family of the deceased, and it is our responsibility to uphold the dignity of both the alive and the dead. In the Islamic Republic of Pakistan, we have put forward the disposal in a plastic well-compacted bag as the best choice of laying down the dead, and perform the Islamic ritual of praying in congregation, funeral prayer, to seek pardon for the expired Muslim; but of course, the standard protocol has to be followed, by limiting the number of persons and maintaining a safe distance of about 2 meters or more between each attending Individuals. The risk from not following protocol is catching the horrible disease, which may be mild like dry cough and fever, to severe COVID dragging the patient down to his deathbed.

The physicians can only provide the symptomatic treatment, helpless if souls start leaving their bodies despite providing the highest quality of medical care. Known definite risk factors are old age, underlying illnesses (e.g. diabetes, heart disease, AIDS, etc.) but we have yet to figure out the risk factors for healthy young patients.

One day they’re okay, the next day they require intubation. [It’s] one of scariest parts of this disease,” says Dr. Rochelle Walensky, Chief of infectious diseases at Massachusetts General Hospital and Professor of Medicine at Harvard.[8] 

Thence, such an enigmatic pathology ought to be dealt with the greatest caution. These perilous times call for absolute dedication by the Messiah of our nation, and & it is their principle right and our foremost duty that we follow each and every protocol set forth to play our part in flattening the curve.

References

  1. Burke D. Coronavirus preys on what terrifies us: dying alone [Internet]. CNN World. 2020 [cited 26 April 2020]. Available from: https://edition.cnn.com/2020/03/29/world/funerals-dying-alone-coronavirus/index.html
  2. Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, Xiao W, Yao S, Mei W, Chen X, Luo A, Sun L, Cook T, Behringer E, Huitink JM, Wong DT, Lane-Fall M, McNarry AF, McGuire B, Higgs A, Shah A, Patel A, Zuo M, Ma W, Xue Z, Zhang LM, Li W, Wang Y, Hagberg C, O’Sullivan EP, Fleisher LA, Wei H. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth. 2020; Available from: doi: 10.1016/j.bja.2020.03.026. 
  3. Perisetti A, Gajendran M, Boregowda U, Bansal P, Goyal H. COVID-19 and gastrointestinal endoscopies: current insights and emergent strategies. Dig Endosc. 2020; Available from: doi: 10.1111/den.13693.
  4. Stickings T. First case of a DEAD patient passing on coronavirus is reported in Thailand after medical examiner is infected [Internet]. Mail Online. 2020 [cited 26 April 2020]. Available from: https://www.dailymail.co.uk/news/article-8217471/First-case-DEAD-patient-passing-coronavirus-medical-examiner-reported-Thailand.html
  5. GHERT-ZAND R. Forensic pathologists beware: COVID-19 lives on in blood after death [Internet]. The Times of Israel. 2020 [cited 26 April 2020]. Available from: https://www.timesofisrael.com/forensic-pathologists-beware-covid-19-lives-on-in-blood-after-death/
  6. Hanley B, Lucas SB, Youd E, Swift B, Osborn M. Autopsy in suspected COVID-19 cases. J Clin Pathol. 2020;73(5):239-242. Available from: doi: 10.1136/jclinpath-2020-206522. 
  7. Gearty R. Detroit Police Department 911 dispatcher dead of coronavirus [Internet]. Fox News. 2020 [cited 26 April 2020]. Available from: https://www.foxnews.com/us/detroit-police-department-911-dispatcher-died-of-coronavirus
  8. Resnick B. Scientists are trying to figure out why Covid-19 hits some young, healthy people hard “The infection enigma,” explained. [Internet]. Vox. 2020 [cited 27 April 2020]. Available from: https://www.vox.com/science-and-health/2020/4/8/21207269/covid-19-coronavirus-risk-factors

Conflict of Interest

The author declared no conflict of interest.

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