Rajan Gandhi
Life of any living being is too precious, more so for human beings under any circumstances. COVID-19 pandemic has created peculiar crisis conditions, especially in UT of Jammu and Kashmir, ‘Crisis of Accountability’. There are clear cut MHA and MoHFW detailed instructions on pattern of WHO guidelines for every activity right from test to hospitalisation to SOPs to be followed in case of death. All these guidelines are for all those, including managers of health care facilities and mortuaries, religious and public health authorities, families in fact for anyone handling the patient who has died of suspected or confirmed COVID-19. As per latest information, COVID-19 is an acute respiratory illness caused by virus that predominantly affects the lungs, based on current evidence; the COVID-19 virus is transmitted between people through droplets, fomites and close contact. As this is a new virus whose source and disease progression are not yet entirely clear, more precautions have to be used until further medical details are available. It is clear that except in cases of hemorrhagic fevers (such as Ebola, Marburg) and cholera, dead bodies are generally not infectious. Only the lungs of patients with pandemic influenza, that too if handled improperly during an autopsy, can be infectious, otherwise, cadavers do not transmit disease. Preparing and packing the body for transfer from a patient room to an autopsy unit, mortuary, crematorium, or burial site is the most important aspect and medical guidelines are clear for it. Every person handling the patient/dead body has to be extremely particular about hand hygiene, use of personal protective equipment if required, safe handling of sharps, disinfection of bag housing dead body, all instruments and devices used on the patient have to be disinfected. Proper cleaning and disinfection of all environmental surfaces is utmost important aspect.
All staff identified to handle dead bodies in the isolation area, mortuary, ambulance and those workers in the crematorium / burial ground should be properly and compulsorily trained in the infection prevention control practices. As per guidelines right from the removal of the body from the isolation room area to mortuary, the health worker attending should perform hand hygiene, ensure proper use of PPE (water resistant apron, goggles, N95 mask, gloves), all tubes, drains and catheters on the dead body should be removed, any puncture holes or wounds (resulting from removal of catheter, drains, tubes, or otherwise) should be disinfected with 1% hypochlorite and dressed with impermeable material. Utmost caution should be applied while handling sharps such as intravenous catheters should be disposed into proper container. All oral, nasal orifices of the dead body have to be plugged to prevent leakage of body fluids. Dead body has to be placed in leak-proof prescribed plastic body bag. The exterior of the body has to be decontaminated again with 1% hypochlorite. The body bag can be wrapped with mandatory mortuary sheet only. All used/ soiled linen should be handled with standard precautions, put in biohazard bag and the outer surface of the bag disinfected with hypochlorite solution, used equipment should be autoclaved or decontaminated with disinfectant solutions in accordance with established infection prevention control practices. All medical waste must be handled and disposed of in accordance with biomedical waste management rules. Environmental cleaning and disinfection of all surfaces of the isolation area (floors, bed, railings, side tables, stand, etc.) should be done by wiping with 1% Sodium Hypochlorite solution.
SOPs are clear for even transportation of body. Embalming of dead body is not be allowed and autopsies on COVID-19 dead bodies are avoided unless extremely necessary. If autopsy is to be performed for special reasons, the team should be well trained in infection prevention control practices, should use full complement of PPE (coveralls, head cover, shoe cover, N95 mask, goggles/face shield). All details for post-mortem are clearly specified in the guidelines and should be strictly followed. After post mortem body should be disinfected following standard procedures. The body thereafter can be handed over to the relatives after providing proper counselling to the family members about procedures to be followed during cremation/burial keeping in view of their religious sentiments. It is quite clear in WHO, MHA and MHFW guidelines that the body secured in a body bag, exterior of which is decontaminated poses no additional risk to the staff transporting the dead body. The personnel handling the body may follow standard precautions (surgical mask, gloves). The vehicle, after the transfer of the body to cremation/burial staff has to be decontaminated with 1% Sodium Hypochlorite. Even guidelines for cremation/burial are quite clear. Even viewing of the dead body by unzipping the face end of the body bag (by the staff using standard precautions) may be allowed, for the relatives to see the body for one last time. Religious rituals such as reading from religious scripts, sprinkling holy water and any other last rites that does not require touching of the body can be allowed. Bathing, kissing, hugging, etc. of the dead body should not be allowed. The funeral/ burial staff and family members should perform hand hygiene after cremation/ burial. The ash does not pose any risk and can be collected to perform the last rites. Large gathering at the crematorium/ burial ground should be avoided as a social distancing measure as it is possible that close family contacts may be symptomatic and/ or shedding the virus.
Despite all these clear cut guidelines what is happening in Jammu is simply inexplicable as with so much casual approach amounting to dereliction of duties assigned to the particular departments it is clear that those assigned the task are not serious at all. Earlier due to non mass awareness, people of a particular area simply did not allow cremation of COVID victim and in another instance dead body had to be lifted from pyre due to stone pelting by locals. Even after three months of pandemic why SOPs are not followed? Why administration is not able to make people aware of the guidelines, procedures followed and assure them that ample safety precautions have been taken? Why no CCTV coverage of how the patients are handled, treated, how dead bodies are properly taken care of? With CCTV administration can ensure transparency well as proper check on the safety of hospital staff as well as public. Every person has been assigned with a particular job and any dereliction of duty by a single person can break the chain of safety precautions resulting in spread of virus. There is absolutely no scope of negligence. But what followed recently resulting in death of two close relatives during cremation and narrow escape for the son of deceased is simply tragic and amounts to criminal negligence. When as per guidelines it is not mandatory for relatives to use PPE kits, who instructed and then provided relatives PPE kits to wear in 43 degrees of temperature which must have been above 50 degrees at Tawi bank. Ambulance got stuck in sand and no one intervened till one relative was dead and other went unconscious with no one ready to provide any immediate relief for hours together. Police, hospital administration and civil administration are just passing the buck with no one ready to own the responsibility of serious procedural lapse and it seems no one is clear about guidelines to be followed. Magisterial enquiry has been ordered to be conducted by same person who is supposed to supervise this whole affair. Like many others in the past it just seems to be a ploy to buy time and then move the things under carpet. One hopes better sense prevails and accountability is fixed this time with exemplary punitive departmental action against the culprits. After all, it is a question of credibility, accountability and justice.
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