The Sindh government issued a standard operating procedure (SOP), prepared on recommendations from experts, for families to perform the last rites of their loved ones who have fallen victim to COVID-19.
The SOP aims to devise a methodology which is convenient to and safe for all involved in performing the last rites of such victims, keeping in view religious, cultural and customary considerations without compromising the health of near and dear ones.
It says: “Infection communication by a living COVID-19 person is through contact or coughing or sneezing (droplet transmission). While the latter is obviously not the case after death, care is needed in contact with the body.” The SOP states that secretions coming out of natural orifices may harbour the virus, and people touching the body or coming in contact with body secretions can acquire the virus. The safety of those handling the body is of prime importance.
“Adequate body disinfection in the hospital as well as at ghusl (washing) and kafan (shrouding) virtually eliminates the risk. To date, there is no evidence of a person having become infected from exposure to the bodies of persons who died of COVID-19. Beyond shrouding (kafan) there is no need for government or administration personnel to be involved; the body should be handed over to the family for further rites like janaza and burial.
“The dignity of the dead should be respected along with sentiments of the family. All measures should be taken to fulfill the religious rituals as far as possible.”
Steps involved
Measures will be taken at hospital by hospital staff. Death is to be declared by a registered medical practitioner, with COVID-19 as the cause of death based on positive PCR test (nasopharyngeal swabbing) done in patient’s life. All tubes, drains, and catheters attached to the dead body should be removed.
Fill all openings or wounds the patient may have, such as mouth, nose, ears and tracheotomy openings by using cotton balls or gauze dipped in 0.5% chlorine solution. Wrap the corpse with a double-layer cloth sheet (preferably soaked with 0.5% chlorine solution). Plastic bags are needed where leakage of fluid is seen. Outside of these bags may be wiped with 1 in 4 diluted household bleach and allowed to dry. No need to disinfect the body itself at this stage.
Once the corpse has been removed, clean all the environmental surfaces with 0.5% chlorine solution and soiled clothes wrapped up separately for washing with bleach containing solution. Relatives are to be counseled and consoled by hospital administration/district administration. They must be counselled regarding the procedure to follow and may be reassured that they will be taking part in the burial procedure. They can be shown the face of the deceased if they wish so; however, touching the body, in any case, shall not be allowed.
Communication of information to the district administration shall be ensured immediately after the death by the hospital administration. Grave designation/booking is to be done soon after the death (see below under burial). There is no need for any designated graveyard for COVID-19 deceased patients.
Steps at home
All the steps described above are to be ensued by staff designated by the district administration. However, they should be using PPE kits (mentioned below) and taking infection control precautions. Relatives present at the spot may look at the body without touching or kissing and a distance should be maintained of at least one meter with the body.
Numbers of family members present at the site should be kept to a minimum for infection control precautionary measures. Children, older people over 50 years of age, and those with heart or chronic lung disease, diabetic, hypertensive, immunocompromised or ill people will not be allowed to attend any of the last rites.
Designated team
A designated and trained team of two or three persons is enough for transportation and Ghusl/Kafan procedure. This should be identified by the district administration. The team members should take infection control measures and wear PPE kits.
Personal Protective Equipment kits for persons involved in the whole procedure, including relatives, include disposable gloves (non-sterile, ambidextrous), or a heavy-duty glove, an impermeable, disposable or washable plastic gown, a face protection, goggles or a face shield and a surgical mask.
Footwear: Rubber boots, or if not available, shoes with puncture-resistant soles and disposable overshoes
Hand hygiene with sanitiser or soap/water, has to be performed by those handling the body before and after handling the body; after touching patient’s surroundings
Transportation
Ghusl and kafan are to be ideally performed at designated places of voluntary organisations involved, with prior understanding with the district administration. The Ghusl place should be notified prior to transportation. The body of the deceased has to be escorted to the ghusl place on a stretcher, in a vehicle (usually provided by a voluntary organisation, otherwise arranged by the district administration). Those involved in transportation should take usual infection control precautions. The vehicle should be cleaned after the procedure with chlorine containing solution. There is no harm in transporting the body from one district to another subject to adherence to infection prevention protocols.
Bathing & shrouding
This should be done as soon as possible after death. A place should be designated in major cities by the district administration, ideally at designated places of voluntary organisations. In case, where this is not available, and death occurs at home, ghusl can be given at home but only by personnel designated and trained by the district administration, who should also ensure infection control precautions in such cases. Such practices are risky and all attempts should be taken to get trained persons of voluntary organisations involved at home.
A team of 2-3 volunteers trained and dressed in PPE as mentioned above should perform ghusl. If relatives wish to participate, one member can be allowed with all precautions as for regular members along with designated team.
In case of death and ghusl at home, the district administration should ensure supply and wearing of PPE for the family members participating in the ghusl.
Females should be present at the ghusl of a female and males for a male. Wash the body in the prescribed Islamic way. Avoid direct contact with blood and body fluids. Extra caution must be taken while washing the mouth, eyes and nose. These should be gently washed to avoid splash of water.
Cover any open wounds with bleach-soaked cotton or gauze. Upon completion of the ghusl, dry the body and the table underneath while rolling the body, from one side to another
The shrouding (kafan) should be done at the same place, by the same team using the same PPE kits. Usual cloth that is used for kafan is adequate. In case where a lot of oozing of secretions was observed during the ghusl, wrapping the body in a plastic sheet with cloth may be preferred, though not mandatory, to avoid the soiling of kafan cloth unexpectedly.
Clean all the surfaces e.g. washing the table with 0.5 % bleach wearing PPE kits after the corpse has been taken away. Any contaminated linen should be washed separately. The coffin is not mandatory; the body can be carried on stretcher or other carriers as available in coffin vehicles. There should be no wastage of time beyond shrouding up to the burial.
The body may be handed over to the relatives to carry out the rest of the burial procedure as usual. No special dress or PPE is required by those taking part in the process beyond shrouding.
The face of the deceased may be seen by removal of face cover subject to condition that persons removing must wear gloves and mask. Moreover, hand hygiene is necessary for those involved. However, proper disposal of masks and gloves will be ensured. Carrying the body on a stretcher or other formal carriers on shoulders has no risk to others.
Funeral prayers
The funeral prayers can be offered at the usual place, at masjid or at a graveyard. There is however risk of infection transmission between attendees at other gatherings. Hence limiting the number of those offering prayers and distancing between them are to be strictly ensured. Family members should be properly counselled on this aspect by the district administration.
Burial
There is no need to designate a separate burial place for COVID-19 deceased. They can be buried in the usual graveyards. There is no need for any special dimension of the grave. Usual graves can be used. Avoiding crowd at the burial site is however to be avoided. A ninimum number of people should be involved to avoid cross infection between people.
Relatives can lower the body in the grave in the usual way taking help of cloth sheets. Wearing gloves and masks is highly recommended. Using slabs to cover the grave followed by mud cover, as is the usual practice, can be done. Usual hand washing is enough after the burial for those carrying out the procedure.
