Year : 2020 | Volume
: 6 | Issue : 2 | Page : 69--74
Autopsy procedure and standards for deaths of unknown cause during the COVID-19 pandemic
Ningbo Institute of Criminal Science and Technology, Ningbo Institute of Criminal Science and Technology Research, Ningbo, Zhejiang 315000, China
Ningbo Institute of Criminal Science and Technology Research, Ningbo, Zhejiang 315000
At any time during the current coronavirus disease (COVID-19) pandemic period, forensic pathologists of public security departments in China may come in contact with corpses of unknown or unclear disease history. When these forensic pathologists perform autopsies on corpses with unknown cause of death, they inevitably face a high risk of severe acute respiratory syndrome coronavirus 2019 (SARS-CoV-2) infection throughout the autopsy process. In the present paper, the various aspects of the autopsy procedure for corpses with unknown cause of death, including preautopsy preparations, personnel protection, autopsy operations, postautopsy disinfection, and equipment requirements, were explored on the basis of relevant laws and regulations such as the Law of the People's Republic of China on Prevention and Treatment of Infectious Diseases, characteristics of the novel coronavirus and COVID-19, guidelines for epidemic prevention and control, the guiding opinions on the regulation of on-site inspection and handling processes during the COVID-19 pandemic period issued by the ministry of public security, and the current practices of public security forensic pathologists. Recommendations for the autopsy procedure and protection measures for public security forensic pathologists during the COVID-19 pandemic period have been proposed to provide a reference for frontline forensic pathologists and judicial authenticators.
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Pang H. Autopsy procedure and standards for deaths of unknown cause during the COVID-19 pandemic.J Forensic Sci Med 2020;6:69-74
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Pang H. Autopsy procedure and standards for deaths of unknown cause during the COVID-19 pandemic. J Forensic Sci Med [serial online] 2020 [cited 2020 Sep 18 ];6:69-74
Available from: http://www.jfsmonline.com/text.asp?2020/6/2/69/289286
In the midst of the current coronavirus disease pandemic, both medical personnel and public security officers working ceaselessly on the front lines are exposed to huge health risks. As a result of case investigations, forensic pathologists of public security organizations may encounter corpses with an unknown or unclear disease history during the pandemic period. When performing autopsies on corpses with unknown cause of death, these forensic pathologists inevitably face a high risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection throughout the autopsy process.
The present knowledge of the physicochemical characteristics of the SARS-CoV-2 (previously referred to by the trial name, 2019 novel coronavirus) originates from previous studies of SARS-CoV and Middle East respiratory syndrome coronavirus. SARS-CoV-2 is known to be sensitive to ultraviolet (UV) irradiation and heat, and it can be effectively deactivated by heat treatment at 56°C for 30 min, ether, 75% ethanol, chlorine-containing disinfectants, peracetic acid, and lipid solvents such as chloroform, but not by chlorhexidine. The main modes of transmission for SARS-CoV-2 include respiratory droplets and contact routes (including transmission through the conjunctiva and nasal mucosa). In addition, the presence of the virus has also been detected in the urine and stools of patients, which demonstrates the possibility of transmission through the gastrointestinal tract or through aerosols. Systematic research on the viability of SARS-CoV-2in vitro or in corpses. However, from relevant studies on other coronaviruses, it can be deduced that SARS-CoV-2 may have greater resistance in external environments, especially low-temperature environments. In addition, the virus may survive and remain active for several days in the corpses of COVID-19 victims. Therefore, the risk of SARS-CoV-2 infection can only be effectively averted and prevented through improvements in the autopsy procedure and standards as well as the enhancement of personal protection and environmental disinfection measures during the pandemic period.
There are few reports on specific standards related to the autopsy procedure for case investigations. In the present paper, the various aspects of the autopsy procedure for unknown cause of death, including preautopsy preparations, personnel protection, autopsy operations, postautopsy disinfection, and equipment requirements, were explored on the basis of relevant laws and regulations such as the Law of the People's Republic of China on prevention and treatment of infectious diseases, rules for criminal case on-site investigation and examination by public security organizations, standards for the autopsy of patients with infectious disease or suspected infectious disease, guidelines for the disposal of remains of patients with novel coronavirus-infected pneumonia (trial), notice on the autopsy of cases with novel coronavirus-infected pneumonia, guiding opinions on the regulation of on-site inspection and handling processes during the COVID-19 pandemic period, and the current practices of public security forensic pathologists. Recommendations for the autopsies of corpses with unknown cause of death by public security forensic pathologists during the COVID-19 pandemic period have been proposed to provide a reference for frontline forensic pathologists and judicial authenticators.
Based on the current clinical knowledge, the nucleic acid test is considered the gold standard method of diagnosis of COVID-19. A single positive result is sufficient to confirm diagnosis, and two negative results combined with other examinations are sufficient for the temporary exclusion of COVID-19. During the external postmortem examination, prescreening can be performed using a rapid antibody test on blood samples or nucleic acid testing of nasopharyngeal and rectal swabs to determine the possibility of COVID-19 infection in the corpse, so as to provide early warning, facilitate effective protection, and enhance mental preparedness in personnel.
Autopsy Rooms and Requirements
Corpses of individuals with suspected SARS-CoV-2 infection are subject to autopsy if litigation is involved or if the cause of death is unknown, as stipulated by law. At present, there are no autopsy rooms in public security organizations of China that satisfy the requirements for biosafety level 3 (P3) facilities. Therefore, it is difficult for public security personnel to perform autopsies in organizations qualified to perform autopsy on patients with infectious disease designated by health administration departments at provincial level or above, as stipulated by the guidelines for the disposal of remains of patients with novel coronavirus-infected pneumonia (trial). It is recommended that forensic pathologists select normal autopsy rooms for corpses with infectious disease or autopsy rooms for decomposing corpses that satisfy the Construction Standard for Autopsy Laboratory (GA/T 830-2009). This ensures that the following necessary conditions for autopsy rooms are fulfilled: (1) a fully enclosed autopsy room with an auxiliary room; (2) minimum area of autopsy room = 15 m2; (3) independent air and water treatment systems; (4) proper personnel, material, and air flows (with the ability to generate negative pressure); (5) sufficient lighting and auxiliary equipment; (6) equipped with personal protective equipment (PPE), autopsy table, autopsy instruments, photographic equipment, measurement equipment, disinfection and isolation equipment, pathological tissue extraction table, specimen preservation equipment, and corpse preservation facilities; and (7) treatment and disposal of contaminated water and materials are performed in accordance with environmental protection regulations. The existing levels of personnel and environmental protection in these rooms should then be enhanced to cater to autopsies during the COVID-19 pandemic period.
The autopsy protocol and a backup plan should be carefully formulated to ensure adequate protection of all participating personnel, compliance with epidemic prevention and environmental protection regulations, and availability of substitute personnel during emergency situations.
In a comprehensive consideration of the requirements for biosafety, forensic identification, and laboratory examinations, fresh corpses should be autopsied 12 h after death. Apart from two or more personnel performing the autopsy operations and the photographer, participation by nonessential personnel should be minimized, and observation by unrelated persons should be disallowed. If necessary, the autopsy process may be broadcasted in real-time for remote guidance, so as to minimize the risk of contamination to personnel.
Prior to autopsy, advance notification should be provided to the autopsy room to facilitate preautopsy disinfection. When the corpse is moved into the autopsy room, the corpse and autopsy table should be sprayed with 75% ethanol solution, and the floor surfaces should be sprayed or wiped with a 1000 mg/L chlorine-containing disinfectant solution. Subsequently, the internal environment and air of the autopsy room should be disinfected by UV irradiation in the absence of personnel for at least 30 min before commencement of the autopsy process.
The levels of personal protection for medical personnel are as follows: normal, Level 1, Level 2, and Level 3 protection. Under normal circumstances, forensic personnel will come in contact with the blood, body fluids, secretions, and excretory material of patients during the autopsy process. Therefore, the minimum level of protection required for such personnel is Level 2 protection, which includes the following: medical protective mask, work uniform, isolation gown or coverall, shoe covers, gloves, and work cap. During the spread of an infectious disease or an epidemic, forensic personnel should strictly adhere to the standards of Level 3 protection, which involves the use of protective goggles, a face shield, or a full-face protective respirator in addition to Level 2 protection.
Standards for donning personal protective equipment
Currently, forensic pathologists in many parts of China have not adopted strict personal protection measures during autopsies. Normal nonwoven disposable surgical gowns or autopsy gowns, which only provide normal protective effects or lack anti-permeability, are used in certain regions. This increases the risk of occupational exposure in forensic pathologists during day-to-day autopsy practice. The use of medical disposable hooded coveralls such as the DuPont™ Tyvek coverall, 3M™ medical protective coverall, or Lakeland coverall is recommended. Such products, which are soft and lightweight, are mostly produced using high-density polyethylene or polypropylene. As they are 100% particulate-tight, the penetration of body fluids, blood and viruses, and bacteria in blood can be effectively prevented. To prevent injury during autopsy operations, cut-resistant gloves may be used as the outermost layer of gloves.
PPE must be donned in a specific order to ensure correct and rapid donning, which enables maximum protection and lays the foundation for safe doffing after use.
The correct sequence for donning PPE is as follows: protective mask, first layer of gloves, coverall, shoe covers or rubber boots, second layer of gloves, isolation gown, third layer of gloves, protective goggles, and protective face shield.
After performing hand disinfection, put on a high-efficiency filtration mask (N95). Check the tightness of the mask straps, place, and hold the mask over the mouth and nose with one hand, and fasten the mask straps. Place the fingertips from both hands at the top of the metal nosepiece, and mold it to the shape of the nose by pushing inward while moving the fingertips down both sides of the nosepiece, so as to ensure airtightness of the mask. Check for air leaks by placing both hands at the edge of the mask while inhaling and exhaling deeply. Alternatively, a cartridge respirator can be usedPut on the first layer of latex glovesDon the coverall from the bottom up (without putting on the hood), zip up and secure the fastening straps. The sleeves of the protective suit must cover the first layer of gloves. Put on the hood of the protective suit and depress the pull-tab of the zipper to prevent downward sliding. Cover exposed areas in the front of the neck with tape and fold the outer edge of the tape outward to facilitate removal after usePut on the waterproof rain boots, pull the trouser legs of the coverall down to encase the rain boots, secure the trouser legs at the bottom with tape, and fold the outer edge of the tape outward to facilitate removal after usePut on the second layer of latex gloves, ensuring that the sleeve cuffs of the coverall are enclosed in the gloves. Secure the gloves at the wrists with tape and fold the outer edge of the tape outward to facilitate removal after use.If the coverall is not waterproof, a disposable waterproof isolation gown should be worn over itPut on the third layer of (cut-resistant) glovesPut on the protective gogglesPut on the protective face shield and ensure that areas of the face surrounding the eyes are coveredOperating personnel should cooperate with each other to verify the proper donning of PPE.
Autopsies must be performed in accordance with relevant standards. Only the minimum number of essential personnel should be involved in each autopsy. Record-taking during the autopsy process can be performed using a recorder pen or a speech recognition system. Apart from necessary assistance, autopsy operations at the same site of the corpse by multiple persons should be avoided. The principle of alternate operations should also be adopted for photographing and testing to prevent contact between personnel. The following should be noted during autopsy operations:
Reports have indicated the presence of SARS-CoV-2 in the blood, sputum, mucus, stools, and urine of COVID-19 patients. To reduce the risk of infection, movements during autopsy operations should be as gentle as possible to prevent the splatter of blood and body fluids. Adoption of the dry autopsy method is recommended. The use of high-pressure water jets for the rinsing of bloodstains or other stains on the corpse should be avoided; stains should be carefully rinsed using a moist towel or running water at a low speedThe use of an electric saw during the autopsy process should be avoided if possible. If opening the cranium is necessary, an oscillating saw should be selected, and towels soaked with 75% ethanol solution should be placed on both sides of the saw blade to prevent the raising of bone dust and splattering of bloodAs SARS-CoV-2 mainly infects the respiratory system, high viral loads usually occur in organs within the thoracic cavity of infected patients, such as the lungs, trachea, and bronchi. Therefore, immense caution must be exercised when opening the thoracic cavity. The dissection and observation of the trachea and bronchi should be performed at a safe distance with gentle movements to avoid compressing the lungsWhen the abdominal cavity is opened, rapid gas release may occur as decomposed intestines may have ruptured from bloating. To prevent contamination, openings in the abdominal cavity should be covered with towels soaked with 75% ethanol solutionDuring the autopsy process, 75% ethanol solution may be sprayed in the autopsy zone and surroundings at any time. However, strict precautions must be taken to minimize the risk of fireIf there is a risk of contamination arising from tears in the coverall or glove or injury during the autopsy process, the relevant personnel must immediately withdraw from the autopsy for emergency treatment.
Sample collection and preservation
Forensic autopsies performed during case investigations by public security organizations to determine the cause of death differ from pathological autopsies in the necessity of extracting all biological samples that can provide clues for investigation, contribute evidence for trials, enable revelation and confirmation of the nature of cases, and facilitate personal identification. Such samples include but are not limited to blood (spot), saliva (spot), semen (spot), sweat (spot), sputum (spot), nasal mucus (spot), vomitus, hair, bone, stool, and relevant organs and their contents. Routine DNA samples and physicochemical samples must be collected, and pathological samples are only collected when necessary.
For DNA samples that are normally stored in paper bags, each paper bag should be stored separately in a clearly labeled airtight bag. All samples should be placed in a dedicated airtight container, and the external surfaces of the container should subsequently be disinfected with 75% ethanol solution or a chlorine-containing disinfectant.
Stomach, liver, blood, and urine samples for physicochemical testing, and trace evidence, should be separately stored in airtight containers and subsequently placed in clearly labeled airtight bags. All samples should be placed in a dedicated airtight container, and the external surfaces of the container should subsequently be disinfected with 75% ethanol solution or a chlorine-containing disinfectant.
Intact organs should be extracted as pathological samples to minimize dissections and observations within the autopsy room. Samples should be soaked in high-concentration formalin for 24 h before testing or further sample extraction and re-fixation. Pathological samples should be stored in airtight containers, and the external surfaces of the containers should subsequently be disinfected with 75% ethanol solution or a chlorine-containing disinfectant.
At present, the criminal science and technology laboratories of public security organizations are incapable of attaining the required biosafety levels. Therefore, samples must be transported in a timely manner to relevant testing facilities in dedicated vehicles by dedicated personnel, with no personnel changes and transfers during the transportation process to prevent secondary biological hazards. Laboratories should be reminded to adopt adequate protection measures on receiving and testing the specimens and perform laboratory disinfection after testing.
Postautopsy Handling Procedures
On completion of the autopsy, the corpse should be placed in a body bag with at least 2 layers, which should then be sealed, knotted and immediately transferred out of the autopsy room to a mortuary for disposal. The mortuary should be adequately informed about the suspected infection, and corpse disposal should be performed in accordance with the guidelines for the disposal of remains of patients with novel coronavirus-infected pneumonia (trial).
After the autopsy has been completed, the doffing of PPE and disinfection must be performed in strict accordance with the correct sequence and standards. The correct doffing of PPE is the first step in ensuring that the risk of contamination is reduced, as all previous protection efforts will be wasted with the failure to pay attention to detail during any step of the doffing process. Under normal circumstances, the autopsy gown is simply removed and disposed of upon autopsy completion. However, during the pandemic period, the following procedure must be carefully followed in the doffing of PPE: check PPE, remove isolation gown, remove third layer of gloves, remove protective face shield, remove second layer of gloves, remove protective goggles, remove coverall, remove shoe covers or rain boots, remove first layer of gloves, and remove protective mask.
After glove disinfection, unfasten the isolation gown and remove by rolling the gown inside out, ensuring that its outer surface is completely encased in the inner surface. Place the used gown into a pedal bin in a slow and careful mannerAfter glove disinfection, remove the third layer of (cut-resistant) glovesAfter glove disinfection, remove the protective face shield according to the following steps: Lean forward slightly and raise head, gently pull the elastic band of the face shield with both hands, remove the face shield in a back-to-front direction, discard face shield or place in a designated container for disinfectionAfter glove disinfection, remove the second layer of glovesAfter glove disinfection, remove the protective goggles according to the following steps: lean forward slightly and raise head, gently pull the elastic band of the goggles with both hands, remove the goggles in a back-to-front direction, and discard goggles or place in a designated container for disinfectionAfter glove disinfection, remove the coverall with the assistance of a second person according to the following steps: Unfasten the zip and fastening straps, pull off the hood of the coverall from the back of the head with both hands, remove the coverall from the shoulder to the waist area, pull the hood towards the back with both hands and roll the coverall inside out until the feet are freed, ensuring that both hands do not come into contact with clothing inside the coverall and the outer surface of the coverall is completely encased in the inner surface. Place the used coverall into a pedal bin in a slow and careful mannerAfter glove disinfection, remove the shoe covers or rain bootsAfter glove disinfection, remove the first layer of glovesExit the autopsy zone and enter the buffer room. After hand disinfection, remove the protective mask, ensuring that both hands do not come into contact with the outer surface of the maskWash hands with running water using the seven-step procedure, disinfect the entire body surface by spraying with 75% ethanol solution, enter the changing room, return to the clean zone, and disinfect hands with disinfectant solution.
Commonly used high-level medical disinfectants such as chlorine-containing disinfectants and peracetic acid are corrosive to metals, whereas autopsy tables, certain autopsy instruments, and transport tools usually contain large amounts of stainless steel. In actual practice, it has been proven that the use of chemical disinfectants results in substantial corrosive damage. Quaternary ammonium disinfectants can be used with stainless steel products but produce certain corrosive effects on instruments, tools, and objects made of copper, aluminum, and other nonstainless-steel metals. A 75% ethanol solution may also be used, as SARS-CoV-2 is sensitive to alcohol. Different methods of disinfection or combinations of multiple disinfectants should be selected for different materials. Freshly prepared disinfectant solutions should be used to ensure their effectiveness.
Disinfection of autopsy instruments and supplies
Common disinfection methods for medical instruments, including UV irradiation, ozone, alcohol, and thermal disinfection, can effectively kill SARS-CoV-2. Disinfection using UV irradiation or ozone, which is easily operated and can be performed under room temperature and humidity conditions, is the most rapid and convenient method of disinfection for special instruments (unable to withstand high temperatures and high pressures). Forensic disinfection cabinets achieve disinfection through UV irradiation, far-infrared irradiation, high temperature and ozone, which enables the thorough killing of viruses and bacteria without further cleaning and soaking. Tools and rulers used during the autopsy should be washed and placed in a forensic disinfection cabinet for disinfection. Rain boots, protective goggles, and face shields can be washed and disinfected by spraying with a 1000 mg/L chlorine-containing disinfectant solution or UV irradiation for at least 30 min. Records of disinfection should be made accordingly. Recorder pens and cameras can be disinfected by wiping with 75% ethanol solution followed by UV irradiation for at least 30 min.
Disinfection of premises
Upon autopsy completion, the autopsy room, thawing room, floor surfaces of corpse transport passages, autopsy table, photography table, and pathological tissue extraction table should be immediately cleaned, and waste material should be disposed of in a timely manner. After cleaning the stains on the autopsy table with water, disinfection should be performed by wiping with a 2000 mg/L quaternary ammonium disinfectant solution or 75% ethanol solution, with care taken to ensure that anionic surfactants such as soap or powder laundry detergent are not used simultaneously. Floor surfaces should be washed or mopped using water followed by disinfection through mopping or spraying with a 1000 mg/L chlorine-containing disinfectant solution. When chlorine-containing disinfectants are used for the disinfection of floor surfaces, care must be taken to avoid contact with the autopsy table and ventilation hood, and ethanol must not be used simultaneously. Finally, UV lamps should be switched on for at least 2 h to achieve disinfection of the entire autopsy room. UV lamps within the autopsy room should be configured based on an average intensity of ≥1.5 W/m2. After cleaning and disinfecting, records of the use and disinfection of the autopsy room should be made.
Disinfection of transport tools
Trolleys and stretchers that have been used to transport corpses should be washed with water and subsequently sprayed or wiped with a 2000 mg/L quaternary ammonium disinfectant solution, with care taken to ensure that anionic surfactants such as soap or powder laundry detergent are not used simultaneously. Disinfection can also be performed by spraying with 75% ethanol solution, but strict precautions must be taken to minimize the risk of fire.
Waste material should be disposed of in accordance with the regulations stipulated in the provisions on autopsy of cadavers of patients with infectious diseases or with suspected infectious diseases (Order No. 43 of the Ministry of Health of the People's Republic of China) and the regulations on the administration of medical wastes (Order No. 380 of the State Council of the People's Republic of China).
Medical mask with a N95 or KN95 rating or above compliant with the GB19083-2010 standard; medical surgical mask compliant with the YY0469-2011 standard; cartridge respirator. Disposable, to be discarded after one-time use.
Medical disposable coverall compliant with the GB19082-2009 standard. To be discarded after one-time use.
Face protection equipment
Sealed chemical splash-proof goggles with headband, protective face shield. Can be reused after thorough disinfection.
Disposable hood cap, latex gloves, cut-resistant gloves, waterproof shoe covers, rain boots (high-top), tape, recorder pen, camera, spray bottles, towels, etc.
Disinfecting supplies and tools
75% ethanol solution, chlorine-containing disinfectant, quaternary ammonium disinfectant, glutaraldehyde disinfectant, quick-dry hand sanitizer, disinfecting wipes, etc. When preparing and using chlorine-containing disinfectants at high concentrations, a mask and gloves should be worn to avoid inhalation and skin contact.
Only UV lamps that emit UV light at 253.7 nm can be used. Lamp tubes must be replaced regularly or wiped regularly with 75% ethanol solution. Nail lamps (wavelength: 365 nm), UV banknote detectors (wavelength: 365 nm), and aquarium UV sterilizers (wavelength: 320–400 nm) do not provide disinfectant effects.
Forensic disinfection cabinets and medical UV disinfection cabinets. UV disinfection cabinets for home use, especially models equipped with a ventilation system, are not recommended as viruses may effuse and escape into the environment from the air vent.
Measures and Recommendations
Autopsy is an extremely important means of forensic identification. The accuracy of forensic opinion is of great significance to the revelation and elimination of crime. As public security organizations place great importance on the investigation of murder cases and the consciousness toward evidence in criminal litigation has significantly increased, the improvement of necessary work conditions, strengthening of occupational safety, and widespread construction of standardized autopsy rooms should be placed on the agenda of relevant authorities. In addition, improvements should also be made to the Construction Standard for Autopsy Laboratory (GA/T 830-2009) to address the failure of public security autopsy facilities to satisfy the requirements stipulated in the notice on the autopsy of cases with novel coronavirus-infected pneumonia and the notice on the issuance of guidelines for the disposal of remains of patients with novel coronavirus-infected pneumonia (trial) during the COVID-19 pandemic period.
The universal use of medical-grade protective equipment such as N95 masks and medical coveralls by public security forensic pathologists is recommended, so as to realize the enhancement of occupational protection and reduce the risk of exposure to various bacteria and viruses. Logistics support departments should establish a strategic reserve system for protective equipment used by technical departments. In particular, as a higher level of protection is required for autopsies, a short supply of protective equipment during a major epidemic will seriously impact routine case investigations and efforts in battling the epidemic.
Although virtual autopsy (virtopsy) techniques possess advantages of objectivity, high accuracy, and noninvasiveness, deficiencies in imaging techniques have led to certain limitations, resulting in the inability of virtopsy to completely replace conventional autopsy under current legal and evidence system. Similarly, minimally invasive testing techniques can only provide limited pathological diagnoses and are incapable of replacing autopsy during the pandemic period.
Rapid developments in modern medicine over several centuries have led to the gradual incorporation of modern technologies such as robotics into the medical field. In certain major hospitals, surgical robots (da Vinci surgical system) have already been utilized in minimally invasive surgeries. It is hoped that the emergence of intelligent autopsy robots in the future will provide an effective means of avoiding contamination from specific autopsies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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