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Infectious Diseases

07 May 2020

Covid-19: How deaths are treated in the Free State

John Hlangeni was the first person known to have died of Covid-19 in the Free State. Refilwe Mekoa spoke to his family and found out more about how the dead are handled in Mangaung.

On 31 March 2020 the Free State province reported its first Covid-19 death, and South Africa’s third.

The man who died was 85-year-old John Hlangeni. Whether he was the first or the third, to his family Hlangeni was more than just another Covid-19 statistic. When Spotlight recently spoke to his family members, their grief was still fresh. Hlangeni’s son, Gopolang Hlangeni, says his father was an avid reader who enjoyed telling stories. “He loved spending time with his great-grandchildren and watching wrestling with them on TV.

He was a soft man who enjoyed spending his time doing the Lord’s work. My father was a pastor at the Global Reconciliation Church and a respected man in his community. ”The family believes Hlangeni would still be alive if he had initially been tested for the virus and not just screened. Screening refers to checking for Covid-19 symptoms such as fever and dry cough, while testing refers to taking swabs from inside the mouth or nose and testing the samples in a laboratory. 

Free State health authorities traced Hlangeni after he attended a church service that resulted in the province’s biggest cluster outbreak. The three-day church gathering was held from 9 to 11 March. A total of 895 people attended and over 70 Covid-19 cases were identified from the event. Spotlight tried to confirm the exact number of people identified, but the Free State Department of Health did not respond by the time of publication.

Gopolang says results of the screening initially came out negative and his father only became ill later. “The thing about screening is that it doesn’t mean if you’re not infected today, you won’t be infected tomorrow,” says Professor Shabir Madhi, a Professor of Vaccinology at the University of the Witwatersrand. He says that what we now know about the virus is most people that are infected won’t even have symptoms. “The purpose of screening in the community is to isolate those individuals, to trace their contacts and put them in quarantine to reduce the rate of transmission. It is impossible to test all 58 million South Africans and you would need to test them every three to four days. If they test negative today, it doesn’t mean they won’t be infected three to four days later,” he says.

The funeral

After Hlangeni died, his family was told to view his remains for the last time before being wrapped. They were told the remains needed to be “covered”. Gopolang says his father’s remains were kept in the morgue of Pelonomi Hospital. Their undertaker was told to fetch the remains only on the day of the funeral. It remained at the morgue for four days. Hlangeni died the Monday morning and was buried on the Friday of that same week.

Gopolang says the family didn’t see the need of keeping the remains of their father for longer because the funeral could only be attended by close relatives. In terms of the Regulations to the Disaster Management Act, only 50 or fewer people may attend a funeral. The 60-year-old Gopolang describes the funeral as something different from what they are used to in their culture. He told Spotlight that environmental health officials and the police were present throughout the entire process.

A register was kept of everyone who came to the family house and also during the funeral service at the burial site. The register is kept for contact-tracing of cases, should the need arise. “Everyone who came to the house before, during and after the funeral had to write down their names and contact details,” Gopolang explains. “We were not allowed to see the body at the funeral. There were only close relatives present, and they were fewer than the expected number of fifty people.

"The undertaker came with the corpse from the hospital on the day of the funeral and once it arrived at home, the procession immediately went to the graveyard,” Gopolang says. “A backhoe was used to fill the grave unlike what we’re used to in our culture where men will use spades to fill the grave. This,” Gopolang says, “was to ensure there is physical distancing between all of us.” The police monitored the funeral and environmental officials came to the house after the funeral to disinfect the place. “

My father’s funeral took about an hour as opposed to the almost six hours we are used to,” says Gopolang. After the funeral, everyone in the  Hlangeni household, including relatives, got tested. Four of Hlangeni’s family members, including his 81-year-old wife, tested positive for Covid-19. All four of them were placed in isolation at Pelonomi Hospital, some for sixteen days while others for over twenty days. 

Stricter measures

Since Hlangeni’s passing, stricter measures on the handling of the remains of Covid-19 victims have been implemented by affected municipalities across the country, including the Mangaung Metro. The municipality recently released a statement saying the remains of Covid-19 positive persons should be considered a “biohazard”. In the statement, the municipality calls for stricter measures because they say Covid-19 remains may cause severe human disease and may also present a high risk of spreading the virus. 

Madhi doesn’t agree with Mangaung’s measures and says there’s no scientific basis for such recommendations. “There’s no other country in the world that is considering a corpse of someone who died of Covid-19 a biohazard. All that needs to happen is that the same type of precautions that are exercised with any other corpse needs to be adhered to. You need to wear a mask and cover your hands when you’re handling the corpse. This is not Ebola; in fact, it’s more of a biohazard to deal with someone who has died of HIV than to deal with someone who has died of Covid-19,” he says. “We won’t get any reports of anyone being infected through the cadaver with Covid-19 because of handling the body. It’s highly unlikely.” 

Dr Sabeehah Vawda, a virologist from the School of Pathology at the University of the Free State (UFS), is less critical of the measures and believes the municipality’s decision is most likely based on advice from experts within the Departments of Health and Environmental Health. Vawda says there is definitely a need for regulations on the use and disposal of Personal Protective Equipment (PPE) and hygiene practices for all individuals involved in handling the remains of the deceased.

Vawda stresses that it is important to understand that SARS-CoV-2, the virus  that causes Covid-19, has only recently been discovered and information about it, its transmissibility and effects are constantly being updated based on new research. “Since the virus has been shown to survive for prolonged periods on different surfaces, there is a possibility that the corpse may still harbour the infectious virus on the surface, which may pose a small risk of viral transmission to those handling the body,” says Vawda, while also acknowledging that according to the WHO, there is to date no evidence of persons having become infected from exposure to the bodies of persons who died of Covid-19.

The Department of Health has developed Covid-19 Environmental Health guidelines, which provides more details. The World Health Organisation (WHO) also issued guidelines on Infection Prevention and Control for the Safe Management of a Dead Body in the Context of Covid-19. Repeated attempts to get a comment from the municipality on this issue were unsuccessful.

Undertakers get Covid-19 training

Meanwhile, as the Covid-19 death toll rises, plans to educate funeral undertakers in Mangaung are underway. The municipality has trained undertakers, as some will eventually deal with the remains of people who died of Covid-19. The municipality’s guidelines specify that remains will be kept only in designated health facilities’ mortuaries. Upon death, the remains are moved from the health facility (a hospital or isolation centre) to the designated mortuary. Where necessary, a Forensic Pathology vehicle will transport the remains.

Godfrey Lehasa is the owner of Lehasa Funeral Directors in Mangaung and is one of the funeral undertakers who were trained in the guidelines of handling the remains of people who died of Covid-19.  Lehasa tells Spotlight during the training health officials educated him and his staff on the basics of the Covid-19 pandemic. The training lasted about an hour. Lehasa, who is also a member of the South African Mortuaries Association in Mangaung, believes that besides the training, undertakers still need to empower themselves by going the extra mile and educating themselves about the pandemic.

Lehasa is concerned that not all mortuaries in the area received training, which might cause problems in the future.  “I believe you need to remain cautious as an undertaker,” he says. “You should always stay alert and handle every single body as if it’s a Covid-19 corpse and take standard precautionary measures. Undertakers are not the first people expected to attend [to] a Covid-19 corpse once a person dies –  it is the health department. They take the body, disinfect it and put it inside a body bag. I learned (through the training) that when it comes to Covid-19, you need to double your efforts of handling such a body,” Lehasa says.

He gave an example of what happens in Bloemfontein. “If a Covid-19 patient dies, they’re moved (from the health facility) by officials with their full protective gear to the forensic truck (a refrigerated trailer serving as a makeshift morgue). So, the body is being wheeled and stored at a specific morgue; from there it will only be removed when it is taken straight to a graveyard,” Lehasa says.

Pelonomi Hospital has an isolation area to accommodate Covid-19 patients. In terms of the regulations, the Covid-19 remains are disinfected to avoid cross-contamination and the processes are supervised by environmental health officials. Vawda says the safety and well-being of everyone who tends to bodies should be a priority, while they still maintain respect for the dignity of the deceased and their families. “Family members need to be counselled regarding the possibility of transmission so that they understand the need for the stricter regulations. All the surfaces, items, instruments and vehicles that the corpse has been in contact with, should be appropriately decontaminated. The decision to bury or cremate depends on family, traditions and current regulations from the municipality. There are no specific requirements for the cremation of all those who die from Covid-19,” says Vawda.

Rising numbers

Meanwhile, the Free State Health Department announced on 3 May the latest death in the province of a 51-year-old man. According to a statement, the man presented underlying health conditions consistent with other Covid-19 deaths around the world. He was treated at Pelonomi Netcare Private Hospital where he succumbed to the virus. This raises the number of deaths in the province to six, so far. By Tuesday (5 May) the tally for confirmed Covid-19 cases in the province stood at 126 with 96 recoveries. According to the department, 794 049 people have been screened in the province and 9 152 have been tested. 112 of the province’s cases were in Mangaung. Provincial Health Spokesperson Mondli Mvambi says they will intensify screening and testing across the province to ensure they reach out to all the areas.

Stigma and hope

Although Gopolang lost his father, he is happy that his mother who got gravely ill, and his family members have all fully recovered. He says people should not just rely on screening. “It is best to test immediately and not wait for the symptoms. I’m saying this because my father was initially screened and they couldn’t detect anything. Only after he got gravely ill, the virus was detected. But, unfortunately, it was too late. Among my four family members who tested positive, two of them also didn’t have symptoms, but the virus reflected once they tested. This may pose as a risk because many without symptoms could be infecting people without even realising it. So, it’s very important to test,” says Gopolang.

According to Madhi, one problem that South Africa faces is that even when people get tested, it takes between five and seven days to get Covid-19 results back. He says the process makes it almost worthless, because a person needs to get the results back within 24 hours, so that if they come back positive, they can be put in isolation and their contacts can be traced.

Even though they express concerns about John Hlangeni not being tested earlier, Gopolang tells Spotlight that the family is nevertheless satisfied with how the entire process was handled by the health department and officials from Mangaung Metro. Reflecting on what the family went through, Gopolang says he thinks they still need counselling from the ordeal. “When media reports started surfacing about the church gathering and news about my father’s death spread, things became hard. It wasn’t easy coping with all of that. There were negative comments from so many people and it became worse on social media. The stigma was too much for us to bear, although we survived in the end,” he says.

Once things have settled, the family plans to unveil a tombstone or hold a memorial service for those who could not attend Hlangeni’s funeral. Hlangeni was also a church leader in his community. Gopolang has some encouraging words for others losing loved ones to Covid-19. “To those going through the same thing, all I can say is there is hope.  Never lose hope. My mother and other family members have proved that people can recover.”

*This article was produced by Spotlight– health journalism in the public interest. Like what you’re reading? Sign upfor our newsletter and stay informed.

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