|Year : 2020 | Volume
| Issue : 2 | Page : 58-61
COVID-19: A challenge for forensic and pathological researchers
Huang Sizhe1, Wang Rongshuai2, Wang Yunyun2, Zhang Junchao3, Zhang Youyou3, Guan Chuhuai3, Zhang Jie3, Yu Yalei3, Tian Qishuo3, Qu Guoqiang2, Liu Qian3, Zhou Yiwu3, Ren Liang3, Liu Liang3
1 Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology; Chongxin Judicial Expertise Center, Wuhan, Hubei, China
2 Chongxin Judicial Expertise Center, Wuhan, Hubei, China
3 Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
|Date of Submission||12-Mar-2020|
|Date of Decision||10-Apr-2020|
|Date of Acceptance||05-Jun-2020|
|Date of Web Publication||09-Jul-2020|
No. 13 Hangkong Road, Wuhan 430030
No. 13 Hangkong Road, Wuhan 430030
Source of Support: None, Conflict of Interest: None
Coronavirus disease 2019 (COVID-19) emerged in Wuhan, Hubei province, in December 2019, then spread rapidly in a very short time resulting in thousands of deaths. Unfortunately, details about the pathological mechanisms involved in the disease – including those associated with death – are currently scant. It is important to perform autopsies and pathological examinations of patients who have died from COVID-19 as soon as possible. This is the responsibility of forensic and pathological researchers, but it does pose various challenges. Such autopsies should be conducted in an isolated operating room under constantly maintained negative pressure. The examiners should be protectively equipped in accordance with biosafety level 3 requirements. It is essential to disinfect the room, facilities, instruments, and materials after the procedure and to dispose of all wastes appropriately. Cautious and precise operations during autopsies and pathological examinations will minimize the possibility of viral transmission. As many autopsies of COVID-19 patients as possible should be performed, until a detailed understanding of the mechanisms involved in COVID-19 pathogenesis and death has been attained.
Keywords: Autopsy, coronavirus disease, forensic medicine, severe acute respiratory syndrome
|How to cite this article:|
Sizhe H, Rongshuai W, Yunyun W, Junchao Z, Youyou Z, Chuhuai G, Jie Z, Yalei Y, Qishuo T, Guoqiang Q, Qian L, Yiwu Z, Liang R, Liang L. COVID-19: A challenge for forensic and pathological researchers. J Forensic Sci Med 2020;6:58-61
|How to cite this URL:|
Sizhe H, Rongshuai W, Yunyun W, Junchao Z, Youyou Z, Chuhuai G, Jie Z, Yalei Y, Qishuo T, Guoqiang Q, Qian L, Yiwu Z, Liang R, Liang L. COVID-19: A challenge for forensic and pathological researchers. J Forensic Sci Med [serial online] 2020 [cited 2020 Aug 5];6:58-61. Available from: http://www.jfsmonline.com/text.asp?2020/6/2/58/289281
| Introduction|| |
In December 2019, an epidemic of a novel type of pneumonia began to emerge in Wuhan, China. On February 11, 2020, the World Health Organization (WHO) announced the novel disease named coronavirus disease-19 (COVID-19), and the virus responsible for it named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). On January 20, 2020, the National Health Commission of China classified COVID-19 as a “class B infectious disease” and enacted a prevention and control policy as “class A” with reference to the Law of the People's Republic of China on the Prevention and Treatment of Infectious Diseases. After COVID-19 began spreading rapidly around the world, on March 12, 2020, the WHO declared the outbroke a pandemic. As of April 9, 2020, the total global number of confirmed patients was >1,400,000, and the death toll was >85,000. COVID-19 has overwhelmed multiple health-care systems globally, at least partly by way of its strong infectivity, long incubation period, and variable clinical manifestations and outcomes. Patients can exhibit respiratory symptoms, digestive symptoms, or both, and the symptoms can be mild or severe. While most infections are not debilitating, some patients become critically ill and a minority of those patients die. To date, a lack of detailed information about the pathogenic mechanisms involved in COVID-19 has hindered effective treatment.
| Indispensability of Examinations and Autopsies of Covid-19 Deaths|| |
SARS-CoV-2 inevitably evokes people's memories of the SARS virus that emerged in 2003. The first autopsy of a patient infected with that virus who died was conducted in Guangdong, China. Through autopsies and death investigations, it was confirmed that a virus was the causative pathogen, as the virus inclusion body identified, and aspects of pathological changes associated with infection were characterized., The virus was detected positive in other organs in addition to the lung, prompting suggestions that SARS-CoV may be transmissible through nonrespiratory routes. Those findings and accumulated knowledge derived from pathological examinations of SARS patients played important roles in guiding the diagnosis and treatment of COVID-19. SARS-CoV-2 is a different virus, however, and it should not be dealt with based solely on the knowledge derived from SARS-CoV.
Pathological reports on COVID-19 include one of which a patient who had a lung tumor complicated with COVID-19, and resected lung tissue sampled through pneumonectomy was pathologically examined. In another report, pathological examinations were performed on lung, heart, and liver biopsy sampled from a patient died of COVID-19. In those reports, however, owing to limitations of the sampling methods, not all the vital organs could be examined, and potentially informative changes may have been missed. Other organs that may have been attacked by the virus, such as the brain and spleen, were not biopsied. The complete spectrum of pathological mechanisms of COVID-19 and their potential interactions with preexisting diseases remain to be determined. Therefore, ongoing systematic and comprehensive pathological investigation is required. Many pathological and forensic experts have emphasized the urgency of performing examinations and autopsies of COVID-19 patients. Health authorities in China have responded to these proposals and published a series of policies designed to guarantee that examinations are conducted.
| Biosafety Protection|| |
Autopsies of COVID-19 patients who have died need to be conducted thoroughly, but they also need to be conducted differently to general autopsies. Specific characteristics and tissues of potential interest need to be examined and collected, but this needs to be done while minimizing the possibility of secondary infection. Fortuitously, much collective insight and experience derived from autopsies of patients with other potentially fatal infectious diseases including the 2004 SARS-CoV and AIDS can be drawn upon.
Current evidence suggests that SARS-CoV-2 is mainly transmitted through droplets and contact (i.e., respiratory tract, oral and nasal mucosa, and eye conjunctiva). Fecal transmission and aerosol transmission may also be possible. Tang et al. reported that active viruses can be isolated from the cadavers of SARS up to 175 h after death, suggesting that examiners are directly exposed to the virus, and emphasized that biosafety measures were essential.
COVID-19-related examinations should be conducted in an isolated area that is strictly divided into contaminated, buffer, and clean zones, with corresponding disinfection facilities, access routes, and cleaning procedures. Facilities should be equipped to meet basic needs such as light and water, but more importantly, to maintain constant negative pressure and ensure the discharged gas and water is virus free. Cleaning and disinfection procedures should be performed consistently and correctly before and after examinations, by spraying/wiping with hospital disinfectants, or ultraviolet light exposure for at least1 h.
Ideally, autopsies and examinations should be conducted in facilities that are certified biosafety level 3 or higher, or provide a comparable level of protection. It is not possible to establish an ideal facility in a short time in or near an epicenter, but with appropriate alterations, isolated shelters or operating rooms equipped with proper facilities can meet the required protection standards.
It is best to restrict the number of examiners present during examinations of COVID-19 patients/cadavers, and only operators and recorders should be permitted to attend, to reduce the possibility of infection. Strict personal protection measures must be taken seriously. Anyone entering the laboratory should wear personal protective equipment that is as protective as the US National Institute for Occupational Safety and Health certified N95, European Union standard FFP2, or equivalent., At the least, that equipment should include gloves, a medical mask, goggles, a face shield, gowns, and a waterproof apron. All examiners must know how to put on, use, take off, and dispose of their safety equipment correctly, and the seal check should always be performed. The wearing of cut-resistant gloves is recommended, to reduce the risk of blood transmission through accidental wounds. If occupational exposure does occur, the examiner requires immediate and adequate treatment, followed by self-isolation and medical observation.
Sufficient medical instruments and supplies should be prepared in advance to avoid people unnecessarily exiting and entering the laboratory during the examination. Single-use materials and disposable instruments should be used wherever possible. Unsterilized instruments cannot be taken away from the laboratory after the examination, including unused ones. Instruments should be cleaned and disinfected thoroughly before the next examination. Spraying/wiping with 75% v/v ethanol or exposure to ultraviolet for at least 1 h is recommended for some devices such as camera or digital record that are not appropriate to be disinfected by disinfectant or ultraviolet, which are recommended to have a plastic bag to cover over.
Greywater and waste will inevitably be generated and need to be safely managed to avoid the possibility of secondary transmission or contamination. It is recommended that reusable instruments and equipment be washed with 0.5% sodium hypochlorite solution, and that greywater be disinfected using a proper drain facility before it is disposed of. Waste should be collected in designated containers, then disinfected or treated appropriately.
| Autopsy and Examination|| |
Autopsies should be conducted systematically and comprehensively, in accordance with the standards of infectious diseases. The computed tomography scan showed that the lesions were concentrated in peripheral lung areas, and clinical manifestations appeared dyspnea and asthma, indicating that the respiratory system, thus, requires much attention, including the investigation of changes in different lung lobes from peripheral to central, and each segment of the trachea. It has been suggested that cytokine storm may play an important role in the course of SARS, suggesting that attention should be paid to components of the immune system when examining COVID-19 cadavers, including the spleen and bone marrow. Vital organs such as the heart and brain, as well as body fluid samples including pleural effusion, sputum, blood, and gastric content, should not be ignored. After being extracted and inspected, such samples should be stored in designated containers as soon as possible and appropriately treated depending on the subsequent examinations intended, such as through immersion in formalin or 2% glutaraldehyde. In addition to histopathological observation, it is recommended that to the greatest extent possible, additional investigations such as immunohistochemistry and in situ hybridization should be conducted.
The cadaver or tissue should be placed in a waterproof protective bag during examinations, to avoid contamination caused by the outflow of potentially contagious liquids such as blood. The operation process should be performed carefully to reduce unnecessary cutting and prevent the outflow of fluids such as blood and urine, and gauze and towels should be used as required. The operator should always be mindful of sharp instruments and broken bone ends and engage in gentle and methodical movements to avoid unintended tissue dispersal or liquid splashing.
To date, no studies on the viral infectivity of isolated tissue or body fluid samples are available with regard to SARS-CoV-2, and it is recommended that the staff responsible for sample transfer wear personal protective equipment to prevent infection. Multiple layers of packaging should be used before transporting samples; the packages should be sealed and disinfected in designed containers, and the packages should be marked “COVID-19 related” and their contents should be clearly explained at the point of transfer. The tools and vehicles used for the transfer should be thoroughly disinfected thereafter.
| Learning from Cadavers|| |
COVID-19 is a novel disease in humans, and it is hoped that evidence from examinations and autopsies of COVID-19 deaths will provide insights into clinical diagnosis and treatment and even assist the development of drugs and vaccines, as well as future scientific research. The authors' operation team conducted the first autopsy in mid-February 2020 and reported the preliminary findings to health authorities and clinical workers. Some discoveries have been included in the diagnosis and treatment guidelines released by the National Health Commission of China.
Notably, much about COVID-19 remains to be determined. What is known is that infection with SARS-CoV-2 results in different manifestations and outcomes. How these differences relate to the disease itself is yet to be determined, as are the details of the relationships between COVID-19 and various underlying diseases. The ongoing accumulation of more comprehensive data and detailed analyses of those data will provide some insight. Accordingly, as many autopsies as possible should be conducted, and further studies classified based on age, sex, severity of illness, and other factors are needed in efforts to thoroughly investigate the potential mechanisms involved in COVID-19. These will be ongoing challenges for forensic researchers and pathologists.
We express our sincere appreciation to the health workers and forensic workers around the world who are on the front line. To those patients who are willing to donate their bodies for research, and their families, we express our profound respect and hope that more lives will be saved.
The generation of this report was supported by a COVID-19-Related Emergency Research of Huazhong University of Science and Technology (grant number 2020kfyXGYJ098). This article was partially published in the Chinese language in the Chinese Journal of Forensic Medicine.
Financial support and sponsorship
The generation of this report was supported by a COVID-19-Related Emergency Research of Huazhong University of Science and Technology (grant number 2020kfyXGYJ098).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Ding Y, Wang H, Shen H, Li Z, Geng J, Han H, et al
. The clinical pathology of severe acute respiratory syndrome (SARS): A report from China. J Pathol 2003;200:282-9.
Nicholls JM, Poon LL, Lee KC, Ng WF, Lai ST, Leung CY, et al
. Lung pathology of fatal severe acute respiratory syndrome. Lancet 2003;361:1773-8.
Ding Y, He L, Zhang Q, Huang Z, Che X, Hou J, et al
. Organ distribution of severe acute respiratory syndrome (SARS) associated coronavirus (SARS-CoV) in SARS patients: Implications for pathogenesis and virus transmission pathways. J Pathol 2004;203:622-30.
Tian S, Hu W, Niu L, Liu H, Xu H, Xiao SY. Pulmonary pathology of early-phase 2019 novel coronavirus (COVID-19) pneumonia in two patients with lung cancer. J Thorac Oncol 2020;15:700-4.
Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al
. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020;8:420-2.
World Health Organization. Infection Prevention and Control during Health Care When Novel Coronavirus (nCoV) Infection is Suspected, 19 March 2020: WHO/2019-nCoV/IPC/2020.3. World Health Organization; 2020.
Zhang Y, Chen C, Zhu S, Shu C, Wang D, Song J, et al
. Isolation of 2019-nCoV from a stool specimen of a laboratory-confirmed case of the coronavirus disease 2019 (COVID-19)[J]. China CDC Weekly 2020;2:123-4.
Tang JW, To K, Lo AW, Sung JJ, Ng HK, Chan PK, et al
. Quantitative temporal-spatial distribution of severe acute respiratory syndrome-associated coronavirus (SARS-CoV) in post-mortem tissues. J Med Virol 2007;79:1245-53.
World Health Organization. How to Perform a Particulate Respirator Seal Check. World Health Organization; 2008. Available from:
https://apps.who.int/iris/handle/10665/70064. [Last accessed on 2020 Apr 10].
World Health Organization. Health Workers Exposure Risk Assessment and Management in the Context of COVID-19 Virus: Interim Guidance; 4 March, 2020. World Health Organization; 2020. Available from: https://apps.who.int/iris/handle/10665/331340
. [Last accessed on 2020 Apr 10].
World Health Organization. Water, Sanitation, Hygiene, and Waste Management for the COVID-19 Virus: Interim Guidance; 19 March, 2020. World Health Organization; 2020. Available from: https://apps.who.int/iris/handle/10665/331499
. [Last accessed on 2020 Apr 10].