People wearing masks cross a street in Tokyo's Shinjuku Ward on March 30, 2020. (Mainichi/Shinnosuke Kyan)

Funeral businesses in Japan have been left in a difficult position in the wake of the novel coronavirus outbreak, as they are not always informed of the specific cause of death of pneumonia patients, meaning some bodies must be handled with the same precautions taken for those known to have died from COVID-19.

Amid such circumstances, there have been posts on Twitter suggesting that because there are people dying from pneumonia without confirmation of whether they were infected with the novel coronavirus or not, the actual number of deaths from the virus may be higher than the official figure, though one ministry official says this is unlikely.

The Tokyo Metropolitan Government's Bureau of Social Welfare and Public Health on March 2 sent five funeral industry groups, including those operating hearses and funeral halls, instructions on the cremation of the bodies of people who died from the novel coronavirus, among other issues. The instructions, sent in the name of Hironori Takahashi, head of the bureau's Health and Safety Division, introduced measures to prevent funeral workers and people attending funerals from becoming infected with the new coronavirus.

The instructions state that such bodies are to be placed in impermeable body bags, sealing them from exposure to the outside air, and cremation is to be carried out while taking into consideration the feelings of the family. They also ask hospitals to make sure to inform funeral workers transporting the body that the person had been infected with the novel coronavirus.

A question-and-answer section for related businesses on the website of the Ministry of Health, Labor and Welfare mentions the use of sealed body bags and advises that workers wear gloves when continuing to handle bodies.

Meanwhile, a similar section for medical institutions that hand over the bodies of infected people advises, "After paying sufficient consideration to the protection of privacy, please take heed to inform those transporting bodies and those involved in cremation (about the state of the person who died), from the perspective of preventing the spread of infections."

However, one perplexed official from the Japan Hearse Association said that while health ministry guidelines were followed when transporting the bodies of infected people, there were cases in which hospitals had not informed them of the cause of death. The official said they heard that because of this, when transporting bodies that had not been placed in non-permeable body bags, workers had to decide by themselves what action to take.

This photo shows the second page of a request the Tokyo Metropolitan Government made to funeral industry groups regarding the handling of bodies of people infected with the new coronavirus, from the website of the Japan Hearse Association.

"When it's not clear whether the person has tested negative for the virus in a polymerase chain reaction (PCR) test, we have to protect the health of the driver and others," the official said.

In some cases, funeral industry workers have brought their own protective clothing with them, but some businesses have not been able to prepare such protection, and have had to refuse to transport the body.

It is believed that some hospitals are not telling the workers the cause of a person's death out of respect for privacy. The industry is therefore considering making a request to medical institutions to share the information.

A representative of a separate cooperative association handling weddings, funerals and other ceremonial events said that measures were being taken based on the information on the health ministry's Q&A page, but added, "Depending on the hospital, there are apparently some cases where they will not say whether a person is infected with the coronavirus or not on the grounds of protection of personal privacy. If they told us in advance, we would be able to take measures such as preparing protective clothing.

The Environmental Health and Sanitation Section in the Health and Safety Division of the Bureau of Social Welfare and Public Health, which oversees crematoriums and other such facilities, has reportedly received a number of inquiries from those in the funeral business asking what to do if it is not known whether a person who died from pneumonia was infected with the new coronavirus or not, and whether attendance at funerals should be restricted.

Part of the confusion lies in the fact that the health ministry's notice is merely a "request" and hospitals are not obliged to inform funeral workers of the cause of death. Furthermore, the notice only covers what to do when handling the body of a person infected with the novel coronavirus, but do not provide any direction for cases in which the state of infection is unknown.

Amid such circumstances, in late March a male user identifying himself as a worker involved in preparing bodies for cremation posted a tweet saying, "There are a lot of cases in which testing has not been carried out, so the corpses of untested people who died from pneumonia are treated in the same way, though it's painful to see this. People on the scene are on edge." This post was retweeted some 16,000 times. It was accompanied by an image of a document titled "On the handling of bodies infected with the novel coronavirus," which stated "Cremation is possible even if 24 hours has not passed since death." The document is said to have been received from a funeral company.

Article 3 of the Graveyards and Burials Act prohibits the cremation or burial of bodies within 24 hours of the time of death. Replies to the post on Twitter included the comment, "People are quickly being laid to rest without others knowing whether they were infected or not," while one person said, "I wonder if people are being cremated quickly without testing to make the number of deaths look smaller."

Prime Minister Shinzo Abe speaks to reporters regarding the death of people infected with the novel coronavirus, on Feb. 14, 2020. (Mainichi/Masahiro Kawata)

According the Ministry of Health, Labor and Welfare, however, there is an exception to Article 3 of the law and it is possible to cremate or bury a person infected with the novel coronavirus within 24 hours from the perspective of preventing the spread of infections. In the case of class 1 infectious diseases accompanied by serious symptoms, such as the Ebola virus disease, the bodies are handled within 24 hours in principle, though this is not a requirement in cases where the person was infected with the novel coronavirus.

The image posted on Twitter also mentions keeping the number of funeral attendees to five people or less, but this was apparently not a request from the health ministry, but rather a matter decided by the funeral business.

Regarding the comment about untested pneumonia patients, one internet user responded with the question, "Aren't PCR tests of people who die from pneumonia being carried out?" Other users suggested that some of these people who had died of pneumonia could include infected people and that the official number of deaths from COVID-19 in Japan may not be accurate.

In Japan, pneumonia is the fifth most common cause of death, coming after cancer and heart diseases. Pneumonia claimed the lives of approximately 94,000 people in Japan in 2018. Additionally, there were some 38,000 deaths from aspiration pneumonia, caused by accidentally inhaling food, liquid or other matter into the lungs. Putting these two figures together gives a total of over 130,000. As of March 29, the number of deaths attributed to the novel coronavirus stood at 66.

With regard to the concerns that have been voiced online, an official from the health ministry division handling tuberculosis and other infectious diseases commented, "Including cases of aspiration pneumonia and so on, we do not conduct PCR tests for every person who dies of pneumonia. But in cases where people died of pneumonia for unknown reasons, doctors are required under the infectious diseases prevention law to notify prefectural governors through the local public health center when they have a body of a person who was showing signs of the new coronavirus when they were alive. It's inconceivable that the actual number of deaths (from the novel coronavirus) could become detached from the publicly announced number of deaths."

(Japanese original by Kenichi Omura, Integrated Digital News Center)