Protocols from COVID-19 deaths enough to plague a saint

The year 2020 will be remembered as one of humanity’s deadliest, with the pandemic turning it into a nightmare for billions, restricting every aspect of human activity from traveling to schooling, and claiming nearly 1.5 million lives in less than a year.

Even if when death comes, the rich have no money and the poor no debt, death still offers no solace for suffering COVID-19 patients, as funeral and burial protocols differ significantly from those following fatalities from other causes.

The World Health Organization (WHO) issued general guidance in March – “Infection prevention and control for the safe management of a dead body in the context of COVID-19” – and updated them in light of new studies and data in early September.

In addition, the health authority of every country issued a version of its own, taking into consideration cultures and traditions.

Based on what we now know, the US’ Centers for Disease Control and Prevention (CDC) said it believed there is little risk of contracting the virus from a body.

The US has long been leading the world in terms of case numbers and fatalities, with more than 13.5 million and nearly 270,000, respectively.

"At this time, the CDC states that decedents with COVID-19 may be buried or cremated according to the family’s preferences. However, you should 'check for any additional state and local requirements that may dictate the handling and disposition of the remains of individuals who have died of certain infectious diseases’," it said in its latest advisory in early November.

According to CDC guidelines for Americans, a team is not required and the family can prepare a body with necessary protective gear or wash while wearing a waterproof gown, mask, and goggles or face shield to protect from splashing body fluids. But support could be requested from trained religious leaders and government staff for funeral services.

Unlike Ebola victims, the personal belongings of the deceased can be washed with soap and water or a disinfectant and air-dried in direct sunlight.

No special transport is required and family members can view the body in a casket but must stand at least 1 meter (3 feet) from others viewing the body in line with relevant social distancing measures.

The CDC said the reuse of protective equipment may be necessary given the shortage of supplies, as long as it is properly disinfected.

If the family needs to ship cremated remains, they may only be shipped via US mail, according to the CDC guidelines. No law in any state, however, mandates cremation.

Despite the seemingly downplaying approach by the CDC, handling of coronavirus deaths have created panic and despair in the US, the nation with the highest number of fatalities and infections.

In April, images emerged of wooden coffins stacked for burial in deep trenches in a mass grave in the New York City by workers in hazmat outfits on the Hart Island, a site long used to bury the homeless or poor, who have no next of kin or whose families cannot afford a funeral.

Mexican experience

The Health Secretariat in Mexico said family members can see the body of the deceased with required protective equipment. The report suggests that the body is a vector for the virus, and it should not be "touched nor kissed".

In Mexico, there are more than 1.1 million cases and nearly 106,000 deaths from coronavirus.

After a COVID-19 patient's death, doctors need to inform social workers at the hospital, who then will inform the family members. The medical staff needs to transport the body in a special bag.

In case the family members or those close to the deceased are quarantined due to a possible COVID-19 infection, they need to deliver the birth certificate and official identification of the deceased so the hospital can issue the death certificate.

Funeral homes need to inform that the body is a confirmed or suspected case of COVID-19 so that preventive measures can be implemented.

Funeral services are to be avoided, while, on family members' request, the mourning could be done with a closed casket as long as the services do not last longer than four hours with no more than 20 attendees, and sanitary measures maintained.

If a Mexican national happens to die overseas in a foreign country, the procedures should be carried out through Mexican consulates and embassies.

Graveyards and funeral homes in the country have long been advised to expand their physical capacity to withhold the surge of bodies.

The Mexican government has also decided to intern bodies in public pits. In Tijuana, one of the border cities with the US most affected by the pandemic, the government announced the creation of 3,000 pits.

For non-identified corpses, the protocol dictates that a medical examination must be recorded to differentiate the cause of death, saying: "It is forbidden the incineration of non-identified bodies or identified bodies that haven't been claimed of those who have died or are suspected of having died by SARS-CoV-2."

The federal government prohibited the cremation of the bodies since the early period of the pandemic.

On Nov. 24, an economic support package of 11,460 pesos ($574) was offered to family members of people who passed away due to COVID-19. The packages can be solicited from Dec. 2 by anyone who has lost a family member to the virus.

Protocols in Colombia

Cemeteries and funeral homes were closed and rituals were prohibited until October in the South American nation.

Following a COVID-19 fatality, families received the ashes of their loved ones days after their death. In Colombia, there are more than 1.3 million coronavirus cases and slightly over 36,700 deaths.

Funeral homes have now reopened and are allowed to hold funeral services with limited attendance, as long as they comply with the protocols established by the Health Ministry.

When a person dies due to virus, the funeral service staff equipped with protective gears should remove the body from homes or health facilities in the shortest possible time.

Bodies must be deposited in hermetic bags with a certain degree of thickness. Once sealed and deposited in the coffin, it should not be reopened.

The preparation of the body for burial or cremation should be carried out in the same place of death, and for this purpose, health personnel authorized to handle the body must have protective equipment and follow established bio-security procedures.

The body will be immediately transferred in the funeral car, using the fastest route to the cemetery or crematory service, where the body will be delivered to those responsible for the service.

All virus victims, including the suspected ones, are cremated, and then buried in an individualized grave or put in a vault in the cemetery.

Europe

According to the government guidelines in the UK, a funeral can be attended by up to 30 mourners in burial grounds and crematoriums with social distancing and facemasks, at a time when new temporary morgues are set-up in the Midlands and existing morgues have been increasing their capacities to cope with the new spike in COVID-19 deaths.

As the daily death toll has climbed in the second wave, with the highest daily number of 853 registered a few days ago, and experts estimating as high as 250,000 deaths, cemeteries – especially in Midlands, where most deaths are seen – are reportedly having a hard time in coping with the burials.

Germany’s Robert Koch Institute notes that there has been no conclusive study yet on whether or not the body of a person who died from COVID-19 is infectious.

The fact sheet of the institute serves as a guideline for local health authorities and religious communities for handling dead bodies and safely organizing a funeral in Germany, where regulations and measures vary by state due to the federal system.

It recommends doctors, medical staff, and funeral undertakers, who have direct contact with the bodies, to apply standard protective measures and advises against embalming of bodies. The ritual washing should only be done under strict hygiene rules, it warns.

According to the institute, after the body is prepared for burial and placed in a coffin, no additional protection measure is needed.

Viewing during the funeral service with the casket open poses no risk for mourners as long as the general rules such as physical distancing is observed.

Since Germany went into a partial lockdown on Nov. 2, funeral practices are allowed, but the number of people allowed to attend has been reduced, depending on the size of the venue.

Besides usual coronavirus measures, organizers should keep a register of people who attend the funeral, to assist authorities with contact tracing.

German authorities allow transportation of deceased bodies, including those who died from COVID-19, abroad for burial in proper coffins, provided that the legal requirements are met.

When Italy was the epicenter of the pandemic in Europe in March, images of overwhelmed hospitals and military trucks carrying hundreds of dead bodies to crematoriums provided a grim picture of a country unable to deal with the sheer volume of COVID-19 deaths.

The government banned funerals for safety reasons for about two months and thousands of Italians did not have a chance to say goodbye to their loved ones or to provide them with a dignified burial.

The coffins of coronavirus victims were usually sealed directly at hospital morgues to avoid any risk of contagion and the Italian tradition of families passing by open caskets to give their last farewell to the dead, at churches or at home, was abandoned.

After the curve of the contagion started flattening in May, funerals were permitted again, but with a maximum of 15 people and mandatory face masks.

Now, as Italy struggles to contain a second wave of the contagion, the limit to the number of people attending a funeral or a burial ceremony depends on the space available. It is also possible to visit cemeteries and

Masses can be celebrated, but only under strict social distancing measures and sanitary rules.

In Spain, funerals, like virtually all other social activities, have been limited amid the pandemic. Indeed, a funeral was behind Spain’s first known outbreak in late February – leading to at least 70 people catching the virus and the country’s first lockdown in the town of Haro.

Now, masks are mandatory and hugs are discouraged in the country. During the first wave, the number of attendees at a funeral was limited to three people. Now, laws vary in each region, with the maximum number ranging from 10 to 50 attendees, often depending on whether the funeral is held indoors or outdoors.

Spain has seen more deaths this year than any other in living memory, with the latest excess mortality report showing around 70,000 more fatalities over the course of 2020 than in an average year. More than 44,000 of those lives were officially lost to COVID-19.

Madrid, the hardest-hit region, had to open two massive skating rinks to serve as morgues when there was nowhere left to store bodies. In Barcelona, corpses were held in a three-story parking lot. Some small towns like San Martin de Valdeiglesias ran out of space in their cemeteries.

Africa

In Africa, the COVID-19 pandemic has disrupted many African traditions regarding burial. Before the pandemic, Africans were holding large ceremonies to send off their loved ones, often with hundreds of mourners in attendance.

But with COVID-19 restrictions, all this changed.

In countries like South Africa, only 50 people are allowed to attend burials, and families are not allowed to come into contact with the deceased. Burials should not last more than two hours and can only be attended by close family members.

Health officials dressed in protective gear handle the body and bury it. Prior to COVID-19, most African families, except Muslims, took a week before burying their loved ones.

They would keep the dead body at a mortuary. They would visit the mortuary on a Thursday, wash the body, and place it in a coffin.

On Friday, the body would be taken to the home of the family and stay there overnight for viewing before being buried on a Saturday. Now bodies are also buried on weekdays.

Prior to the lifting of inter-province travels in South Africa, those who died in other provinces would be required to get permits to allow them to transport bodies to their home provinces, but this adversely affected the poor as a dead body was allowed to be transported in a separate car but relatives were not allowed to accompany it.

The poor were forced to be buried away from their homes.

Africans who perished abroad between March and July also had to be buried on foreign soil, as most international travel was restricted then.

Now the bodies of those who die overseas are repatriated but with strict guidelines, such as bodies being buried by health officials dressed in protective gear.

But still, in some extraordinary conditions, some people have flouted the rules, with hundreds of people attending funerals.

Iran, Saudi Arabia

The deafening silence in Iran’s largest cemetery, Behesht-e Zahra, is these days broken mostly by shrieks of wailing relatives, giving a tearful sendoff to their loved ones consumed by COVID-19.

The huge cemetery in southern Tehran, the capital city which registers half of the daily deaths from the COVID-19 in Iran, is struggling to keep up with the pandemic.

From around 150 new graves daily before the pandemic, the cemetery now has to accommodate 350 to 400 dead bodies on a daily basis with fatalities from the virus seeing an alarming spike.

The managers at the cemetery and relatives of COVID-19 victims, explaining the procedure, said those dying of the virus are flown straight to the cemetery from hospitals, where funeral rites are performed by a team of volunteers with strict adherence to safety protocol.

At a large complex tucked away in one specially designated corner of the cemetery, funeral rites are performed for all the dead before their burial.

Volunteers from a religious seminary help with the whole process under the supervision of cemetery managers. Following the funeral rites, the bodies are dispatched to the earmarked graves, and the families are allowed only after the burial in line with strict COVID-19 guidelines.

A cemetery worker told Anadolu Agency that the real struggle starts in hospitals where determining the cause of death sometimes leads to delays in the burial of bodies.

Those who are found to have died of the virus are taken in a special ambulance to the cemetery after the families are informed. With Behesht-e Zahra running out of space, there are reports that the government is mulling the idea of building two more cemeteries in the city.

In Saudi Arabia, the Health Ministry has allocated certain cemeteries for coronavirus deaths while hospitals prepare the bodies under the supervision of the ministry.

From funeral procedures to the time of burials carried out by specially trained workers, certain measures such as limiting the presence of a maximum of 10 family members and social distancing are observed.

Palestine, Tunisia, Jordan, Egypt

In Palestine, Health Ministry has created a sub-division to handle COVID-19 deaths at the onset of the pandemic and it dictates that the bodies of suspected or confirmed COVID-19 victims shall be sent to the mortuary as soon as possible and taken to burial location directly from the mortuary.

Families are strictly forbidden to touch or kiss the body. One properly equipped person from the family will be called in to identify the victim from a one-meter distance. The body must be prepared by a specific staff with the appropriate personal protective equipment. It must be covered by three layers with white cotton linen, a bilayer body bag, and then wiped with a disinfectant.

Religious preparation for the body must be conducted under the supervision of an environmental health officer. Relatives are prohibited from opening the sealed coffin and the officer must ensure this measure be strictly followed.

The Islamic funeral prayer must be done with the presence of fewer people in an open space. The government has also prohibited gatherings in March for condolences that usually take three days.

In Tunisia, the first protocol stipulates that the municipality's workers handle the burial process and sterilize the grave, without involving the families of the deceased while allowing two or three people from the relatives.

A new protocol allows 10 people from relatives to attend the funeral and canceled using bulldozers to place bodies in graves. The Health Accreditation and Assessment Authority of the Health Ministry Dr. Muhammad bin Dhiab said the ministry's new protocol is based on "respecting the ethics of dealing with the deceased's body".

The Jordanian Health Ministry for its part has decided to bury the deceased with coronavirus in the traditional way, by handing over their bodies to their families for burial within public safety protocols, without the need to transfer them to the National Center for Forensic Medicine, according to the official Petra News Agency.

Egypt also follows widely accepted universal guidelines to carry out funerals, however, some Egyptians have reportedly objected to COVID-19 victims being buried in local cemeteries. It went so far that the country now punishes those who impede, disrupt, or prevent the burial of the dead or any of the burial rites by imprisonment or fines.

Pakistan, Afghanistan, India, Bangladesh

Pakistan maintains its closed-casket burial protocol in line with WHO guidelines, where only four family members were allowed to attend until June. But gradually, the restrictions have been relaxed. Currently, there are no strict restrictions although the government still insists on small attendance.

In Afghanistan, despite claims of health officials who say they ensure burials of the COVID-19 victims are carried out according to the WHO guidelines, it is reported that most of the families continue to bury their beloved ones who died at home the traditional way without informing authorities.

In Bangladesh, too, COVID-19 victims are buried no different than the non-virus deaths. The government, however, advises strict hygiene protocols before the burials.

Speaking to Anadolu Agency, Dr. A.S.M. Alamgir, the principal scientific officer of the government’s Directorate General of Health Services, said dead body after burial is not harmful or risky.

“But we have strictly directed concerned officials in the root levels of the country to ensure health directions during a shower of the dead body,” Alamgir said, adding that those who will shower the dead body must use personal protective equipment and remain alert so that the water does not spread in the open places.

“People have become used to dealing with COVID-19. A corona patient died here a few days ago, a huge number of people joined the funeral prayer, and he was buried normally,” Mohiuddin, a resident of Bangladesh’s southern district of Barguna told Anadolu Agency.

According to the Indian protocols, when coronavirus patients die, they are transported directly to the graveyard under strict official supervision with the attendance of very few family members. The Health Ministry guidelines note that bathing, kissing, and hugging the dead body are prohibited.

Cremation protocols are almost the same as burials. The authorities have allowed the family members to take the ash to perform the last rites.

In July, a video was shared on social media in southern Karnataka, where health workers were seen burying bodies of COVID-19 victims disrespectfully in a pit. The video triggered outrage on social media and the workers were suspended.

Several other cases of mishandling of COVID-19 victims have been reported elsewhere in India, urging the government to take action against reckless health workers.