By A.R. Mohamed –
Covid-19 Infection & Burial Of Dead Bodies – A Controversial Issue In Sri Lanka – Brief introduction of COVID-19 Virus & How It Causes The Disease
Viruses are considered as the tiniest of the infectious agents and is known to multiply (replicate) only in living cells and can infect all types of animals, plants and other microorganisms including bacteria; and millions of types of viruses are found in the environment. Generally, viral infections provoke an immune response in humans and animals and help the body to eliminate the infecting viruses under normal healthy conditions. This is why most of the virus diseases such as mumps, chicken pox, measles, common flu, dengue are automatically cured without any specific treatment in normal healthy people.
In 22 studies, involving all the different types of corona viruses that infect humans, it has been found that these viruses can remain infectious at room temperature only for up to 9 days outside the human body. However, the COVID-19 virus which causes the present corona virus infection has been reported to survive on surfaces only for about 72 hours.
The COVID-19 virus which originated from Wuhan, China is a new type of corona virus which has never been seen before except the current outbreak. It primarily spread from person to person by close contacts (up to 3 metres) and by small droplets of the saliva and nasal discharges when infected people cough or sneeze; and also, while breathing and talking when the virus comes out through the tiny respiratory droplets. A person may also get infected by touching contaminated surfaces and then touching the mouth, nose and eyes. By 7th April 2020, the corona virus COVID-19 has affected 209 countries and territories around the world.
Of all the organs in the body, the lungs are the most affected organs by the COVID-19 virus. The lung alveolar cells (which are the lining cells of the lung respiratory units called the alveoli through which the oxygen and carbon dioxide gas exchange take place during breathing) abundantly produce an enzyme called ACE2 which helps the virus to get into these lung cells. Once the virus enters these cells they start multiplying (replicating) inside them and continue to damage these alveolar cells causing breathing difficulties, respiratory failure and may end-up in death. In addition, the virus also attacks the stomach and the intestines as some of the lining cells in these organs also abundantly produces the above enzyme ACE2 favouring its survival.
The changes that occur after death?
Soon after death, the cells of the lungs, digestive tract and other organs of the body continue to die due to lack of oxygen supply and the entire body tends to decompose. As mentioned above, for the virus to multiply, it needs living cells; but after death due to non-availability of living cells and hence no production of the enzyme ACE2, the virus also stops multiplying and with time they also perish. As a dead body does not cough, sneeze, breath or talk, there is hardly any virus that comes-out from this body; except if any discharges come through the natural openings of the body such as the nose, mouth, anal opening etc. However, it is a general practice even in normal bodies to plug these orifices with cotton wool to prevent any leakage, if any. Thus, a dead body will not spread the disease unless people touch or handle these bodies without protective equipment. Thus, compared with a COVID-19 infected person who will keep on spreading the disease to others for a few days to weeks during coughing, sneezing, breathing etc., a dead body is harmless and safe to handle if the proper hygienic precautions are adopted.
From the above brief note on the nature of the corona virus and by reading the WHO guidelines given below, you will be able to reason-out whether there is any danger to humans if Sri Lanka allows the burial of COVID-19 infected bodies.
WHO Guidelines in handling and burial of COVID-19 bodies
In medical practice all over the world, the World Health Organization (WHO) guidelines are mainly considered as the accepted standards (including Sri Lanka). The WHO in an Interim Guidance issued on 24th March 2020 entitled “Infection Prevention and Control for the safe management of a dead body in the context of COVID-19” mentions the following as regards precautions, handling and disposal of dead bodies. (The full text of the guidelines is given here ). The salient features of these guidelines are as follows:
1. Only the lungs of patients with pandemic influenza, if handled improperly during an autopsy (post mortem), can be infectious. Otherwise, cadavers (dead bodies) do not transmit disease. It is a common myth that persons who have died of a communicable disease should be cremated, but this is not true. Cremation is a matter of cultural choice and available resources. To date there is no evidence of persons having become infected from exposure to the bodies of persons who died from COVID-19.
2. The safety and well-being of everyone who attends to dead bodies should be the first priority. Before attending to a body, people should ensure that the necessary hand hygiene and personal protective equipment (PPE) supplies are available.
3. The dignity of the dead, their cultural and religious traditions, and their families should be respected and protected throughout. Hasty disposal of a dead from COVID-19 should be avoided.
4. Ensure that personnel who interact with the body (burial team) apply standard precautions, including hand hygiene before and after interaction with the body, and the environment; and use appropriate personal protection equipment according to the level of interaction with the body, including a gown and gloves. If there is a risk of splashes from the body fluids or secretions, personnel should use facial protection, including the use of face shield or goggles and medical mask.
5. Ensure that any body fluids leaking from orifices are contained. Keep both the movement and handling of the body to a minimum. Wrap body in cloth and transfer it as soon as possible to the mortuary area. There is no need to disinfect the body before transfer to the mortuary area. Body bags are not necessary, although they may be used for other reasons (e.g. excessive body fluid leakage) and no special transport equipment or vehicle is required.
6. Healthcare workers or mortuary staff preparing the body (e.g. washing the body, tidying hair, trimming nails, or shaving) should wear appropriate personal protective equipment according to standard precautions (gloves, impermeable disposal gown, medical mask, eye protection).
7. If the family wishes only to view the body and not to touch it, they may do so, using standard precautions at all times including hand hygiene.
8. Give the family strict instructions not to touch or kiss the body. Embalming is not recommended to avoid excessive manipulation.
9. Adults over 60 years and immunosuppressed persons should not directly interact with the body.
10. In contexts where mortuary services are not standard or reliably available, or where it is usual for ill people to die at home, families and traditional burial attendants can be equipped and educated to bury people under supervision.
11. Apply principles of cultural sensitivity and ensure that family members reduce their exposure as much as possible. Children, older people (more than 60 years old), and anyone with underlying illnesses (such as respiratory illness, heart disease, diabetes, or compromised immune systems) should not be involved in preparing the body.
12. Family and friends may view the body after it has been prepared for burial, in accordance with customs. They should not touch or kiss the body and should wash their hands thoroughly with soap and water following the viewing; physical distancing measures should be strictly applied (at least 1 m between people).
13. People with respiratory symptoms should not participate in the viewing or at least wear a medical mask to prevent contamination of the place and further transmission of the disease to others.
14. Those tasked with placing the body in the grave should wear gloves and wash hands with soap and water once the burial is complete.
15. Although burials should take place in a timely manner, in accordance with local practices, funeral ceremonies not involving the burial should be postponed, as much as possible, until the end of the epidemic. If a ceremony is held, the number of participants should be limited. Participants should observe physical distancing at all times, plus respiratory etiquette and hand hygiene.
16. The belongings of the deceased person do not need to be burned or otherwise disposed of. However, they should be handled with gloves and cleaned with a detergent followed by disinfection with a solution of at least 70% ethanol or 0.1% (1000 ppm) bleach’
What is the issue in Sri Lanka to not allow burials?
The fore-going WHO guidelines clearly permits burial of COVID-19 bodies also according to the Muslim religious rites and practices, including washing of dead bodies; provided the above said hygienic practices are adopted. Also the Quarantine and Prevention of Diseases Act (Chapter 553) also allows burial and the Minister is entitled to make regulations for prescribing the mode of burial. It is mentioned that over 180 countries have allowed burial and many countries have laid-down conditions for burial and also have provided training for burial staff on burial of infected bodies; e.g. Singapore protocols include double-bagging the bodies before they are placed in airtight coffins for burial. Then why are the authorities in Sri Lanka are compelling the Muslims to cremate their dead bodies? Surely 180 countries and the WHO can’t be wrong and consider only Sri Lanka as correct? Is this ignorance on the part of our politicians and professionals or something that is promoted with ulterior motives? One excuse and a suspicion is that COVID-19 virus will contaminate the soil and water and probably spread the disease. There is no scientific evidence whatsoever to prove that this virus spread through water and soil and may spread the disease. If this is so, WHO will never recommend burial. The best example is one of the largest burial grounds which is situated about a half a kilometre away from the Southern sea in the village of Thalapitiya, Galle. In the middle of this cemetery is a large pond where people are bathing day and night. This cemetery and pond are said to be over 400 years old and all types of infected and non-infected bodies are being buried; but up to now there have been no reports of people getting infected or dying by bathing in this pond.
However, for some unknown reasons, the authorities in Sri Lanka give all types of excuses and are compelling the Muslims to cremate the dead with no respect for their religious and cultural sensitivities or even for a dead body. The hurried cremation of the COVID-19 first Muslim victim during the dead of night and the wide publicity given in all the media has caused a fear psychosis, enormous distress and shock-waves not only among the Muslim community but also fear and anguish among others.
As cremation is against Islam and if authorities compel cremation, Muslims being strong in their faith may get scared to report suspected cases or get admitted to a health centre, and this might end-up in a disaster to all. Laws alone will not help to control infectious diseases but more important is to win the hearts and minds of the people to cooperate in order to control a pandemic. The Healthcare Professionals, legal professionals and the related experts should only give their sincere advise to the authorities based on current WHO guidelines, laws of the country, internationally accepted health standards and other proven scientific findings and not on hypothesised theories or unscientific predictions. The government and the people should not be put into pathetic situations, and complicate the delicate peaceful co-existence that is present at the moment. If there is a need to appoint a committee to decide whether burials should be allowed or not, the correct procedure is first to allow the continuation of burials of infected bodies (including COVID-19 bodies) as being practiced for centuries, and the committee to do an in-depth scientific study and to prove that a disaster might occur if burials are allowed. Otherwise, it is unethical and unprofessional for the medical staff and others to recommend cremations violating all international standards, norms and local laws.
Such actions might also end-up in litigations, human rights violations and action by International Human Rights Organisations. By antagonizing the minorities, political repercussions may also occur at the forthcoming parliamentary election (where 36 seats are allocated from the total votes obtained by each party at provincial level and 29 national list seats allocated from the total votes obtained at national level; apart from what is obtained from the votes casted at electoral levels). Thus, even gaining a single minority vote can decide the fate of winning as well as receiving the number of bonus seats at provincial and national levels, unlike the Presidential election where only one is elected.
Hence, considering the existing practices all over the world, International guidelines, local regulations and for other reasons mentioned above, Sri Lanka should allow burials to continue. This is not the time for anybody to take political revenge or advantage over Muslim dead bodies and their community, or play a racial card or compel the Muslims to practice what they are not supposed to do; but now is the time to unite all communities as Sri Lankans and save the country and the nation for all.
*Dr. A.R. Mohamed, PhD (London) – Former Academic and Research Officer