Year : 2020 | Volume
: 6 | Issue : 2 | Page : 75--77
Risk identification and protection during high-risk forensic autopsy
Xia Liu1, Jilong Zheng2, Shengjie Yang1, Cunrui Wei1, Xuesong Feng1,
1 Criminal investigation Detachment of Qingpu Branch, Shanghai Public Security Bureau, Shanghai, China
2 Department of Forensic Pathology, Criminal Investigation Police University of China, Shenyang, China
Department of Forensic Pathology, Criminal Investigation Police University of China, Shenyang 110035
“High-risk” autopsies are those in which the anatomical examination of a corpse entails a substantial risk of contracting a serious infectious disease. Herein, we discuss the risks of infection associated with high-risk autopsies and factors pertaining to risk identification in high-risk autopsies, and we suggest potentially preventative measures focused on anatomy room protection and virtual imaging.
|How to cite this article:|
Liu X, Zheng J, Yang S, Wei C, Feng X. Risk identification and protection during high-risk forensic autopsy.J Forensic Sci Med 2020;6:75-77
|How to cite this URL:|
Liu X, Zheng J, Yang S, Wei C, Feng X. Risk identification and protection during high-risk forensic autopsy. J Forensic Sci Med [serial online] 2020 [cited 2020 Sep 23 ];6:75-77
Available from: http://www.jfsmonline.com/text.asp?2020/6/2/75/289280
Autopsies play a key role in the investigation of deaths, but the capacity of forensic doctors to deal with highly infectious remains is still insufficient, and the risk of occupationally acquired infection is high. Standardized autopsy procedures, personal protective equipment, and biosafety levels can prevent unnecessary occupational exposure. Accurate identification of high-risk cadavers and effective precautions can prevent infections being contracted by forensic and autopsy staff through potentially high-risk autopsies.
High Risk of Infection in Forensic Autopsy
Pathogens currently considered to be “high-risk” at autopsy include SARS-CoV-2, Ebola virus, human immunodeficiency virus (HIV), hepatitis A, hepatitis B, and other chronic viral hepatitis viruses, Creutzfeldt–Jakob disease-causing agents, Lassa virus, tuberculosis, Legionnaires' disease, anthrax, tetanus, typhoid, paratyphoid fever, and meningococcal and streptococcal strains. There have been relatively few reports of HIV positivity being identified in autopsied cadavers in the past. Canadian and German researchers have reported that the HIV positivity rate of autopsied cadavers was <1%., Paterson et al. tested more than 3000 blood samples and did not detect any that were positive for HIV. Susanet al. conducted HIV screening of 300 bodies classified as high risk, and only two were confirmed as HIV positive. Grist and Emslie reported that most laboratory-acquired infections occurred during the course of scientific research, microbiology research, and anatomical process, and that occupational exposure caused tuberculosis in staff in the anatomy room, but there were no reported cases of infections occurring in the forensic autopsy room.
Based on whether they are pathogenic to humans, toxic to humans, can be transmitted to humans, and whether there are effective preventive or therapeutic agents available, four risk categories of pathogenic microorganisms have been devised: (1) Microorganisms that do not primarily infect humans; (2) pathogens that can cause human disease and pose a risk to employees but can be effectively prevented and treated and are not characterized by spread in the population; (3) pathogens that can cause human disease, pose a serious risk to employees, and are associated with a risk of transmission in the population, but for which prevention and available treatments are effective; and (4) pathogens that can cause serious human disease and pose a risk to employees and a potential threat to the population, and for which there is no effective means of prevention or treatment.
Assessing the risk of infection
Assessing the risk of acquired infection in high-risk groups involves five questions: (1) What pathogens are present in high-risk situations; (2) the virulence of the pathogen; (3) the route of pathogen transmission; (4) mechanism of pathogen transmission; and (5) the number of pathogens needed for infection. Accidental exposure to HIV can occur during clinical diagnosis and treatment. In a survey of medical staff treating HIV patients, Gerberding et al. found that a high risk of exposure does not lead to HIV infection, even in cases of needlestick injuries. At present, there is no report of HIV infection during autopsy, which may be related to the lack of routine HIV antibody detection and screening by autopsy personnel. In 2016, a German autopsy staff member developed Lassa fever after handling cadavers infected with Lassa virus.
After the death of a human host, the ongoing viability of infectious microorganisms is affected by the environmental temperature, humidity, and other factors. Tuberculosis, anthrax, and tetanus can survive for many years under various conditions. Virus particles generally do not remain viable beyond 6 or 7 days, but cold storage can prolong the survival of some viruses. Ball et al. detected viable HIV in autopsy samples 11 days after death; therefore, appropriate precautions should be taken when dealing with unfixed HIV-infected tissues or body fluids. After the death of a human host, HIV virus can remain viable for more than 16 days at 4°C, and hepatitis B virus can survive for 7 days in isolated blood stains or other body fluid stains. Tiny blood droplets can contain an infective dose of a virus; therefore, blood spatter during autopsy is a potential source of infection.
Identification of High-Risk Forensic Autopsies
Geller stated “For forensic pathological anatomy, what really can play a protective role is knowledge and cognition, as well as good autopsy techniques and safety practices; in most cases, the greatest risk is not cad cadaver or inadequate facilities, but the pathologist's lack of correct understanding of the potential risk of autopsy.” This also applies to technicians in the anatomy room. Thirty-six percent of pathologists in the United States found that autopsy on HIV deceased had less valuable information and exposure to the risk of HIV infection. However, in order to accurately determine the cause of death, a cadaver must be comprehensively autopsied, even in high-risk cases.
Autopsy, histopathology, and toxicology tests may improve autopsy results pertaining to asphyxia, poisoning, injury, and disease, and a complete autopsy will also include the collection of information about the deceased and an on-site inspection. Crime scene investigation can also assist in identifying high-risk cadavers. Syringes and needles at the scene can indicate a history of drug use. Common sites for intravenous injection include the toe, ankle, calf, forearm, hand, and groin. Venereal disease and chronic anal injury can also suggest the possibility of HIV or hepatitis B infection. High-risk factors for HIV and hepatitis B infection include intravenous drug use, male homosexuality, promiscuity, and prostitution. Increased international travel and communication is also a factor in the emergence, recurrence, and rapid spread of infectious diseases. From December 2019 to March 2020, COVID-19 pneumonia cases have been confirmed in more than 200 countries.
Forensic Autopsy Protection Awareness and Requirements
Autopsy room staff are at risk of infection during their work, especially when dealing with a deceased person who has never been tested for an infectious disease or whose history is not known. Disposable protective clothing and rubber boots are recommended in the dressing room of the dissection room, and protective equipment such as gloves, N95 and above masks, and goggles are put on before entering the dissection area. Wearing double-layer or multilayer surgical gloves and frequent replacement of gloves can reduce the risk of infection through glove breakage. In the United States, the use of metal mesh gloves is increasing. Although they cannot avoid needlestick injuries, they can prevent knife cuts and can be reused after thorough cleaning. In Russia, a kind of “air cushion” that can protect both the respiratory tract and the skin has been used, and its inventor asserts that it has very good protective function. A surgical blade should not be used for periosteum removal or organ extraction, in order to avoid accidental injury caused by blade breakage. A chainsaw should only be used in conjunction with vacuum suction, and it should be thoroughly cleaned and sterilized after use.
All staff involved in an autopsy should be immunized against hepatitis A, hepatitis B, their antibody status should be verified, and they should undergo regular chest X-ray screening. High-risk cadavers should be screened for HIV and hepatitis B, but in practice, routine screening is costly and time-consuming. During a high-risk autopsy, access to the room should be restricted. People suffering from immune deficiency, skin infection, or wounds should not be permitted to enter the autopsy room. Only experienced forensic pathologists and autopsy room staff should examine high-risk cadavers, and the number of people attending the autopsy should be limited.
Anatomy room protection
Good ventilation is a prerequisite for safe work in the anatomy room, and it minimizes the risks of contracting infection through gas and droplets. Professional infectious disease protection brochures, personal protective equipment, and standardized operating procedures are very important for anatomy room technicians and forensic workers in order to prevent infections. A shower room, dressing room, hood, goggles, and masks should be available and used, and separate isolation zones and screening equipment should be available for any additional personnel (doctors, relatives, lawyers, and others) who are required to view the autopsy process. The dissection room should be equipped with hypochlorite, glutaraldehyde, and formalin or sodium hydroxide solution, and other solutions.
Laboratory accreditation of anatomy rooms must be conducted in accordance with the standards of a hospital operating room, and accreditation of forensic pathology examination institutions should be required. Currently, most forensic autopsy rooms have the following deficiencies: (1) A lack of necessary technical conditions and equipment; (2) no additional isolation zone to be used in high-risk autopsies; (3) transportation risks associated with high-risk cadavers; and (4) problems pertaining to the assessment of personnel risk, the assessment of high risk. Laboratory certification of an anatomy room can be conducted based on (1) organization and quality management systems; (2) personnel quality; (3) anatomical site and environment; (4) equipment, information systems, and materials; (5) anatomy room management studies; (6) specific research processes; (7) improvement measures pertaining to the anatomy room; and (8) anatomy room quality assessment and assurance. The quality of pathological anatomic examinations can only be improved if anatomy rooms are systematically certified.
Virtual image inspection
With the development and maturity of imaging diagnostic technology, computed tomography, magnetic resonance imaging, and other digital examination methods have been applied in autopsies. Such modalities are suitable for use in cadavers contaminated with infectious pathogens, toxic substances, radionuclides, or other biological hazards. Although imaging examinations can yield direct pathological diagnoses noninvasively and in real time, they cannot replace traditional autopsy and histopathological examination. In order to reduce the risks associated with high-risk autopsies, noninvasive or minimally invasive methods can be used to examine cadavers suspected of harboring infectious pathogens. In cases in which autopsy, toxicology, and imaging cannot confirm the cause of death, systematic anatomical examination can be conducted. Fryer et al. reported that the use of minimally invasive techniques in high-risk autopsies could reduce the time taken for systematic anatomical examination by two-thirds.
Noninvasive or minimally invasive techniques include clinical history determination, imaging, toxicology, microbiology, biochemical testing, postmortem biopsy, laparoscopy, and thoracoscopy, among others. Virtual imaging can be used in forensic medicine to detect or assess injury, disease, time of death, and time of injury. A large number of case studies have shown that cadaveric computed tomography and magnetic resonance imaging, systematic anatomical examination, and diagnostic imaging can be used to reliably ascertain causes of death in forensic medicine. Virtual imaging can be used as an alternative to traditional autopsy in high-risk cadavers, especially for the detection of fractures, bleeding, lung disease, intracranial lesions, and tumors.
This article was originally released in the Chinese language in the Chinese Journal of Forensic Medicine.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Claydon SM. The high risk autopsy. Recognition and protection. Am J Forensic Med Pathol 1993;14:253-6.|
|2||Little D, Ferris JA. Determination of human immunodeficiency virus antibody status in forensic autopsy cases in Vancouver. Forensic Sci 1990;35:1029-34.|
|3||Penning R, Tutsch-Bauer E, Beer G, Gürtler L, Spann W. HIV infection in legal autopsies. Beitr Gerichtl Med 1989;47:23-9.|
|4||Paterson SC, Vanezis P, Claydon SM. Drug addict deaths in North and West London and prevalence of HIV and hepatitis B infection. Sci Justice 1996;36:85-8.|
|5||Piwowar-Manning E, Fogel JM, Richardson P, Wolf S, Clarke W, Marzinke MA, et al. Performance of the fourth-generation Bio-Rad GS HIV Combo Ag/Ab enzyme immunoassay for diagnosis of HIV infection in Southern Africa. J Clin Virol 2015;62:75-9.|
|6||Grist NR, Emslie JA. Infections in British clinical laboratories, 1986-87. J Clin Pathol 1989;42:677-81.|
|7||Cooper H, Leigh MA, Lucas S, Martin I. The coroner's autopsy. The final say in establishing cause of death. Med Leg J 2007;75:114-9.|
|8||Gerberding JL, Bryant-LeBlanc CE, Nelson K, Moss AR, Osmond D, Chambers HF, et al. Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions. J Infect Dis 1987;156:1-8.|
|9||Ratzan RM, Schneiderman H. AIDS, autopsies, and abandonment. J Am Med Assoc 1989;260:3466-9.|
|10||Lehmann C, Kochanek M, Abdulla D, Becker S, Böll B, Bunte A, et al. Control measures following a case of imported Lassa fever from Togo, North Rhine Westphalia, Germany, 2016. Euro Surveill 2017;22:17-00088.|
|11||Ball J, Desselberger U, Whitwell H. Long-lasting viability of HIV after patient's death. Lancet 1991;338:63.|
|12||Charpentier C, Larrouy L, Matheron S, Damond F, Delelis O, Mouscadet JF, et al. Long-lasting persistence of integrase resistance mutations in HIV-2-infected patients after raltegravir removal. Antivir Ther 2011;16:937-40.|
|13||Geller SA. The autopsy in acquired immunodeficiency syndrome. How and why. Arch Pathol Lab Med 1990;114:324-9.|
|14||Prevention U. Mortality attributable to HIV infection/AIDS-United States, 1981-1990. J Am Med Assoc 1991;265:848-9.|
|15||Yilmaz R, Erkaymaz O, Kara E, Ergen K. Use of autopsy to determine live or stillbirth: New approaches in decision-support systems. J Forensic Sci 2017;62:468-72.|
|16||Wells CL, Juni BA, Cameron SB, Mason KR, Dunn DL, Ferrieri P, et al. Stool carriage, clinical isolation, and mortality during an outbreak of vancomycin-resistant enterococci in hospitalized medical and/or surgical patients. Clin Infect Dis 1995;21:45-50.|
|17||Wunsch MJ, Nakamoto K, Behonick G, Massello W. Opioid deaths in rural Virginia: A description of the high prevalence of accidental fatalities involving prescribed medications. Am J Addict 2009;18:5-14.|
|18||Fryer EP, Traill ZC, Benamore RE, Roberts IS. High risk medicolegal autopsies: Is a full postmortem examination necessary? J Clin Pathol 2013;66:1-7.|
|19||Bolliger SA, Thali MJ, Ross S, Buck U, Naether S, Vock P. Virtual autopsy using imaging: Bridging radiologic and forensic sciences. A review of the virtopsy and similar projects. Eur Radiol 2008;18:273-82.|