COVID-19 casualties: Embalming of dead bodies

Massive publicity of Coronavirus Disease (COVID-19) has inflamed human psyche and emotions. Our existence on this planet is ever since our conception though we celebrate our physical birth days. Human form of life is said to be the best of 2.1 million (2.1x10⁶) living species born through placenta. We have been better than other living creatures due to possession of superior mind, memory, intellect and emotions. We have social bonding with our family and friends. Coronavirus Disease (COVID-19) has taken the shape of a pandemic due to human to human spread of its causative agent. The Chinese authorities isolated this new type of coronavirus from patients of outbreak of pneumonia in December-2019, in Wuhan City of Hubei Province of China during laboratory investigations on 7^th January 2020 and named it 2019-nCoV.

Symptoms of COVID-19 are like influenza and include fever, headache, shivering (rigors), myalgia, malaise, cough and sometimes diarrhea also. In elderly and immunocompromised patients, it is causing severe respiratory distress due to pneumonia and causing death due to comorbidities in-spite of best treatment. Lack of immuno-prophylaxis is the cause of casualties as vaccines for this disease are not available. However, precautionary measures are in force to avoid catching nCoV infection. Personal hygiene, washing of hands frequently with soap and water, wearing of face mask and maintaining physical distance (social distance) from other individuals are the ways to save ourselves from COVID-19. Human to human spread of the disease is through micro-droplets of nasal secretions of infected person.

Need of the hour is to take necessary precautions to avoid catching nCoV infection. COVID-19 could be fatal in 2-3% patients only. Just being positive for 2019-nCoV by RT-PCR does not warrant any panic. Viral infections are self-curing in 95-97 cases with symptomatic treatment. Only 3 to 5% cases would need hospitalization. Imposition of stricter control measures by administration to avoid community transmission of COVID-19 has spread great scare of death in the minds of entire population. People have been avoiding receiving the bodies of their near and dear ones, who unfortunately died of COVID-19 complications.

Let me instill confidence in you that the dead would never spread any infection if bodies are embalmed. We need to maintain social distancing from the living persons and not from the dead. Dead are not exhaling any infectious droplets. Dead need our love and care for proper send off from this world. We could take necessary precautions to sanitize and temporarily preserve the bodies of our near and dear ones who unfortunately bid goodbye to us due to COVID-19 complications. Medical colleges and Medical Research Institutes have been embalming and preserving dead bodies for very long periods for dissection and demonstration to medical students. The history of embalming dates-back to 4000 BC. Egyptians were the first to master the methods of embalming. Why can’t we do embalming of dead bodies before handing over to the relatives?

Provincial governments all over the world should issue advisories to all the hospitals to essentially do hypodermic and surface embalming of dead bodies before handing over to relatives and friends of the diseased. Embalming would ensure safe transportation of the dead body for cremation without any risk of infection. Pathologists and Anatomists should be assigned the task of onsite embalming even if the death occurs at home. Dead bodied of army warriors are always preserved by Arterial embalming along with coloring and masking agents before transportation to native places of martyrs.
 
We have experienced that face mask and alcoholic sanitizers have potential to keep away any infection. Sodium hypochlorite at a concentration of 0.04% in tap water can kill bacteria, fungi and all the viruses including coronavirus. The bleach we use for fabric bleaching at home, contains 4% Sodium hypochlorite (see Figure-1). Sodium hypochlorite at a concentration of 0.04% in tap water is sprayed to sanitize roads and buildings in Containment Zones. One cap full (10 ml) of fabric bleach in 1000 ml (1 L) of tap water gives 0.04% Sodium hypochlorite solution. This solution could be used to sanitize dead body before short distance transportation. Dead body could be wrapped in a bed sheet soaked in 0.04% solution of Sodium hypochlorite. Body could be given bath of this solution.

Figure-1

We trust that eye/ear drops containing just 0.01% (w/v) Benzalkonium Chloride are free of any infectious agents and could be instilled in eyes or ears (see Figure-2).  People can use solution of Benzalkonium Chloride at the universally accepted concentration (0.01% w/v) to surface sanitize dead bodies of their dear ones without any risk of infection. We mop our floors with germicide Lyzol which contains very high percentage of Benzalkonium Chloride (2.4580% w/w: see Figure-3). Just one cap full (15 ml) of Lyzol (500 ml Pack) in 4000 ml (4L) of tap water would give 0.01% solution of Benzalkonium Chloride which could be used for surface sanitization of the dead body. Dead body could be wrapped in a bed sheet soaked in the solution of Lyzol at optimum concentration as cited above.

Figure-2

Figure-3

All relatives and friends of a diseased person should be provided counselling for handling the dead body. People should be educated and encouraged to accept the dead bodies of their loved ones without any fear of infection. Any disrespect to the corpse (dead body) invites applicability of section 297 IPC in India and similar laws must be available in other countries too. Section 297 IPC or similar sections should be invoked both for hospitals and people to show respect to the dead. I would like to appeal to World Health Organization (WHO) for issuing necessary advisory to all the countries to take necessary steps for embalming of the dead bodies during the pandemic for safe transportation for funeral.

Evolution of a pandemic: Coronaviruses to COVID-19

Coronavirus is not an exclusive finding of 2020 though it has been projected as “Novel Coronavirus” (nCoV). The so called nCoV has been designated as etiological agent of “Coronavirus Disease-2019” (COVID-19) that took shape of pandemic with its epicenter at Wuhan City of Hubei Province of China. Bovine and avian Coronaviruses are known since 1976 and a lot of research has already been done on their structure and pathogenicity.

The well characterized members of coronavirus family are positive-stranded RNA viruses. Coronaviruses possess a single-stranded, non-segmented, polyadenylated infectious RNA genome. The size of viral particles (virions) vary from 80-120 nm in diameter. Nanometer (nm) is ultra-small unit of measurement of length. There are one billion (1000,000,000) nanometers in a meter. These viruses could only be revealed through Transmission Electron Microscope (TEM) or Scanning Electron Microscope (SEM). Coronaviruses have pleomorphic look due to 10-20 nm long surface peplomers. Coronaviruses can cause diarrhea, hepatitis and bronchitis in lower mammals and birds. Three species of coronavirus are known to cause hepatitis in mice and seven species of coronavirus are known to cause bronchitis in birds.

Species of coronaviruses are characterized on the bases of molecular weight of surface polypeptides (glycoproteins). The molecular weight of surface glycoproteins of coronaviruses could be ranging from 15,000 to 200,000. They possess a large genome of 5x10⁶ to 8x10⁶ molecular weight. Massive research work has been done on coronaviruses in various virology laboratories all over the world to ascertain their genomic structure.

In the year 2002 “Severe Acute Respiratory Syndrome (SARS) was caused in humans by avian coronavirus (SARS-CoV). The animal reservoir of this coronavirus was perhaps bats. The avian coronavirus spread to other animals like cats and first infected humans in the Guangdong Province of southern China in 2002. An epidemic of SARS-CoV affected 26 countries in 2002-2003 and >8000 cases were reported as per World Health Organization (WHO). The transmission of SARS-CoV is primarily from human to human in the second week of disease due to excretion of viruses in respiratory secretions. So, infection spreads trough droplets of nasal secretion.

The current pandemic with Coronavirus has deliberately been given new nomenclature due to its genomic distinction from SARS-CoV known earlier. This new type of coronavirus causing SARS is called 2019-nCoV.

Symptoms of disease:

Symptoms of COVID-19 are like influenza and include fever, headache, shivering (rigors), myalgia, malaise, cough and sometimes diarrhea also. Fever is most frequently reported symptom, but it may be absent in initial stage especially in elderly and immunocompromised patients.

Cough may be dry initially with shortness of breath. Fever and diarrhea may progress in second week of disease. Elderly and people with associated illnesses like diabetes, hypertension, heart disease or organ transplant, may need special care to protect themselves from COVID-19.

Personal protection measures:

There is no immuno-prophylaxis for nCoV as vaccines are still under development. Personal hygiene, exercise and protein rich diet and vitamin-C are key to avoid coronavirus infection. Fresh fruits or juices rich in vitamin-C, high protein diet, coffee drinks, frequent drinking of warm water could be of great help to keep away COVID-19.

Frequent washing of hands with soap and water. Hand sanitization, wearing of face mask and maintaining physical distance (social distance) of approximately 6 feet would be of great help to avoid 2019-nCoV.

The need of the hour is not to panic but to follow the instructions and guidelines issued by local and national health authorities.

Diagnostic criterion:

Real Time - Reverse Transcription - Polymerase Chain Reaction (Real Time RT-PCR) is the only specific investigation to ascertain 2019-nCoV infection. The Chinese authorities isolated a new type of coronavirus from patients of outbreak of pneumonia in Wuhan City during laboratory investigations on 7^th January 2020 and named it 2019-nCoV.  Nasopharyngeal or oropharyngeal swabs are taken from suspected persons and transported to Laboratories in specially constituted transportation medium.

The principle of RT-PCR detection method is based on ‘Fluorogenic 5’ Nucleage Assay’. During the PCR reaction, the DNA polymerase cleaves the probe at 5’ end and separates the reporter dye from quencher dye only when the probe hybridizes to the target DNA. This cleavage results in the fluorescent signal generated by the cleaved reporter dye, which is monitored almost Real-Time by PCR detection system.

Warnings:

1.      This assay needs to be carried out by skilled personnel only.

2.      Clinical samples should be treated as highly infectious and samples should be prepared in biosafe laminar flow hoods.

3.      Do not use the kit after its expiry date.

4.      Carry out the test as per global standard procedure only.

5.      Avoid repeated freezing and thawing of reagents.

Care and treatment of infected persons:

Infected patients should be managed as per conditions. Patients should be home quarantined or admitted to COVID-19 Hospitals, as per clinical assessment. Symptomatic treatment should be started immediately.  Every patient needs to be instructed to wear face mask and wash/sanitize his/her hands frequently and maintain physical distance from other family members and friends. Proper counselling needs to be provided to patients with adequate supply of diet recommended by nutritionist. Health professionals need to wear ‘personal protection equipment’ (PPE) with adequate sanitization to avoid any cross infection.

Enforcement measures by administration:

Lockdown of public transport, schools, colleges, universities, offices and places of worships may be needed to restrict community transmission and spread of COVID-19. Medical infrastructure needs to be upgraded efficiently for optimum treatment of COVID-19 patients. Thermal screening at Airports, Seaports, Railway Stations and Bus Terminals is the first and foremost step to identify persons carrying virus. Proper arrangements for compulsory quarantine for 14 days of suspects with infection.

 

Investigations should be done as per WHO guidelines for pandemic surveillance. Containment Zones with large number of COVID-19 patients should be put under strict surveillance to avoid community spread of the disease. Strict enforcement of health & hygiene-related discipline could save the citizens and the nation.