New Delhi: The Delhi government’s latest order saying there is no need to test dead bodies for Covid-19 violates the guidelines of both the Indian Council of Medical Research (ICMR) and the World Health Organization (WHO). While the former advises collection of samples after death in suspected cases, the latter stresses classification of Covid deaths.
The ICMR, the nodal body for testing guidelines in India, has maintained that dead bodies of “suspected/latent/unascertained cases” must be tested for Covid-19.
On Tuesday, two days after the Arvind Kejriwal government order was issued, the ICMR in a detailed autopsy guidelines for patients once again directed all hospitals in the country to take nasal swab samples from dead bodies of suspected Covid-19 patients for testing. It further said bodies must not be released from mortuaries until test results are awaited.
The WHO guidelines too clearly state that a death due to Covid-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a probable or confirmed Covid-19 case, unless there is a clear alternative cause of death that cannot be related to the disease.
“There should be no period of complete recovery from Covid-19 between illness and death. A death due to Covid-19 may not be attributed to another disease (eg. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of Covid-19,” it states.
After the order was issued Sunday, Delhi Health Secretary Padmini Singla had told ThePrint the new guidelines aimed to tackle difficulties faced at the field level.
Over the last few days, the Delhi health bulletin has been stating that the cumulative deaths included only those “where the primary cause of death is found to be Covid-19”. This is in contravention of WHO guidelines. On Tuesday, the bulletin also didn’t separately highlight the new recorded infections.
?Delhi Health Bulletin – 19th May 2020?#DelhiFightsCorona pic.twitter.com/hkHN1vZsyU
— CMO Delhi (@CMODelhi) May 19, 2020
ThePrint reached Singla for a comment on the violation of guidelines, via calls and messages, but she didn’t respond. Her office directed the query towards Special Secretary, Health and Family Welfare, S.M. Ali. He didn’t take calls either.
As of Wednesday, Delhi has seen 10,554 Covid-19 cases and 168 deaths.
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Other states not testing patients who have died
Delhi isn’t the only region in the country to say no to collection of samples from dead bodies for Covid-19 testing. The states of West Bengal and Telangana also issued similar instructions — both have faced allegations of under-reporting of cases.
The Mamata Banerjee government has urged health department officials to ensure Covid-19 tests are not conducted on dead bodies. Dr Abhijit Chowdhury, member of a state-constituted task force on Covid-19, confirmed this to ThePrint. “We have standing instructions to not hold any tests on dead bodies for Covid-19,” he said.
The state has reported 2,961 coronavirus cases and 250 deaths.
In April, the Telangana government had also asked all superintendents of government hospitals to not collect samples from dead bodies of Covid-19 suspected patients.
This order was challenged in the Telangana High Court. On 14 May, the court directed the government to collect blood samples of dead persons to verify if they had the infection. The court also told the government to follow the WHO guidelines.
“…such inaction on the part of the state government authorities may cause spread of COVID virus because the relatives of the individual who died might be asymptomatically affected and they may infect other persons with whom they interact, if they are not identified immediately,” the court observed.
Telangana has recorded 1,634 cases and 38 deaths so far.
States doing Covid test on dead bodies
In Maharashtra, which is India’s most affected state at 37,136 Covid-19 cases and 1,325 deaths, the government is clear on conducting tests on dead bodies.
There is no instruction to exempt dead bodies from Covid-19 testing, said a senior health department official, who did not wish to be named.
“It is important to know if the patient was Covid-19 negative or positive and hence we do go ahead and test bodies,” said Dr Akash Khobragade, medical superintendent, St George Hospital, Mumbai.
Punjab also conducts tests on dead bodies if doctors feel there are symptoms.
Dr Rajesh Bhaskar, the nodal officer for Covid-19 in the Punjab health department, said, “Wherever we feel the death might have occurred due to Covid, we do test dead bodies as sometimes a person comes in critical condition and dies even before we could do the test.”
The state has seen 2,002 cases and 38 deaths.
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Experts divided but say classification is important
Dr T. Jacob John, virologist and former chief of ICMR’s Centre for Advanced Research in Virology, said testing dead bodies is meaningless and wasteful of work and expenditure.
However, he added, “Death due to natural illness during the epidemic, unless without any clinical diagnostic criteria, is to be counted as Covid death. Otherwise, what cause of death will be certified?”
During an outbreak, he said, “suspected Covid deaths” must be added to Covid deaths, unless proved they are not such. “If not, there will be another cause of death — the true number of the alternate unproven diagnosis will be inflated, which is unacceptable.”
“In old people or those with comorbidities, if available clinical criteria fulfill Covid (infection/disease), the proximate cause, hence primary cause is Covid,” he said.
Giridhara R. Babu, professor, head, lifecourse epidemiology, Public Health Foundation of India (PHFI), said, “A death related to Covid-19 should be investigated further, with contract tracing and containment, to prevent further spreading. By not classifying the death properly, the transmission can go unchecked.”
PHFI is among the key bodies advising the government on the Covid outbreak in India.
Asked about the ban on testing dead bodies, Babu said, “This is not the right practice as the rest of the country (goes) through hardships of lockdown, you cannot let your guard down by such misclassification-led unchecked circulation.”
Dr Rajnikant Srivastava, head of the department of research management, policy planning and communication, ICMR, told ThePrint, “A death caused by the accident of Covid-19 patient won’t be termed as Covid death. Similarly, death due to cancer will also not be called as Covid-19 death.”
However, he added, “it is 100% call of the treating physician to decide if death was triggered by Covid-19 or any other underlying condition”.
Other countries
In February 2020, the Royal College of Pathologists in the UK had released guidance on postmortem examinations for mortuary workers in suspected Covid-19 cases.
The study observed that there will inevitably be an increase in the number of suspected Covid-related deaths at autopsy. “…if the death is considered to be due to a confirmed COVID-19 infection, an autopsy is unlikely to be necessary and a Medical Certificate of Cause of Death should be given. However, if the infection is involved in a forensic case, then legal duty impels the proper performance of a full appropriate autopsy.”
It stated that the issue of whether a person dies with or “from Covid-19 infection may not always be straightforward, and ongoing epidemiology and available investigation data may shed light on this”.
Similarly, for suspected Covid-19 cases, the Centre for Disease Control and Prevention (CDC), a leading national public health institute in the US, recommends collecting and testing postmortem nasopharyngeal swabs and if an autopsy is performed, lower respiratory specimens (lung swabs).
With inputs from Himani Chandna.
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This order is only for NON-MLC cases.. More specifically to facilitate quick disposal of the dead by cremation as many hospitals are getting overwhelmed by the shear numbers and they are not able to store the dead bodies until the receipt of the rt-pcr report from the concerned laboratory.
However in case of the body being MLC… where there is question regarding the circumstances surrounding the mode and manner of death, Medico Legal Autopsy has to be done… Hence as being properly and successfully practiced in premier Central Govt Medical College like ABVIMS and Dr RML Hospital, such cases swabs will be taken from the dead, sent for testing and after the receipt of the rt-pcr test, we are undertaking Autopsy.
Further if it comes positive, we will get it waived off citing Covid-19.
As repeated many a times, HCW are a limited and precious human resource and they should be protected as they are not easily replaceable. Hence it is safe to say that Forensic Medicine Expert are even scarce as compared to clinical doctors and every effort must be made to ensure safety of all those involved in PM Examination.