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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 50-52

Influence and challenge of COVID-19 in forensic identification


1 College of Forensic Medicine, Hebei Medical University, Shijiazhuang, Hebei Province, China
2 Key Laboratory of Evidence Law and Forensic Science (China University of Political Science and Law), Ministry of Education, Beijing, China

Date of Submission12-Mar-2020
Date of Decision15-May-2020
Date of Acceptance05-Jun-2020
Date of Web Publication09-Jul-2020

Correspondence Address:
Xin Liu
Key Laboratory of Evidence Law and Forensic Science (China University of Political Science and Law), Ministry of Education, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_32_20

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  Abstract 


During the COVID-19 epidemic, the professionals in the field of forensic pathology, forensic sciences in general, and clinical forensic medicine have been performing medicolegal investigation in their communities. The forensic medical personnel who carry out such investigation/identification are facing a great risk of potential infection. Therefore, forensic institutions and forensic examiners should improve their awareness of infection risk and take universal precautions to prevent infection and spread of coronavirus. In addition, forensic experts should abide by the laws when they deal with social unrest and also strengthen research on COVID-19-related medical issues.

Keywords: COVID-19, emergence plans, forensic medicine, infectious disease, prevention and control


How to cite this article:
Cong B, Liu X. Influence and challenge of COVID-19 in forensic identification. J Forensic Sci Med 2020;6:50-2

How to cite this URL:
Cong B, Liu X. Influence and challenge of COVID-19 in forensic identification. J Forensic Sci Med [serial online] 2020 [cited 2020 Nov 26];6:50-2. Available from: https://www.jfsmonline.com/text.asp?2020/6/2/50/289283




  Introduction Top


The COVID-19 pandemic that broke out at the end of 2019 has gradually become more tightly controlled after a period of epidemic spread and expansion in China.[1],[2],[3] However, the pandemic has expanded to other countries and regions worldwide. Moreover, other infectious diseases such as smallpox, cholera, and plague as well as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome, and Ebola virus disease may continue to impact human society. Although some infectious diseases have gradually become under control, new viruses are emerging and new epidemics are quietly approaching the human population. Our understanding of the suddenness, hazards, and relevance of infectious diseases has been deepening since experiencing the SARS and COVID-19 epidemics in China.


  Covid-19 and Forensic Identification Top


Juridical identification involves many specialties and fields, and forensic professional opinions are critical for the court to begin the identification process. Forensic practice often involves face to face with other human beings or performs autopsies on the deceased persons who may have infectious diseases with potential risks of exposing to human secretions with infectious organisms. During the COVID-19 pandemic, the forensic scientists have increased concerns about their own safety and health in the field of judicial identification. After the outbreak of COVID-19, the authors submitted Suggestions on Autopsy of Patients Died of COVID-19 Infection to the Chinese Academy of Engineering on February 3, 2020. This publication was highly valued by relevant decision-making authorities of the central government. Later, upon the request of relevant authorities, we submitted Work Plan for Postmortem Examination of Patients Died of COVID-19. In the campaign against the COVID-19 early epidemic in China, the first systemic autopsy on a COVID-19 patient was conducted by forensic pathologist on February 16, 2020. Subsequently, ten more autopsies on COVID-19 patients were performed. Of the 11 autopsies, 9 were performed by forensic pathologists. The core of forensic pathological examination of COVID-19 cases is to perform systemic anatomical studies of the cadavers and to better understand the pathogenesis of the disease by analyzing organs and tissues of patients who die of COVID-19 infection.[4] Forensic clinical identification requires close physical examination of the living people. Work in the field of forensic psychiatric identification is also growing during the current pandemic. Psychotic patients with asymptomatic COVID-19 infection may exhibit harmful behaviors such as hostility toward forensic psychologists and may become involved in lawsuits and legal disputes. Those who are scared or anxious because of the COVID-19 pandemic may develop mental abnormalities that might lead to behaviors endangering society. Hence, these individuals' disposing capacity and their capacity to bear responsibility must be identified. In the fields of forensic anthropology, forensic toxicology analysis, and forensic material evidence, all identification activities related to COVID-19 might be carried out. After the pandemic, sporadic cases may continue to be present. A new outbreak might follow the current spread. Therefore, institutions and professionals involved in forensic identification should have sufficient knowledge of risk identification and enact risk prevention measures.[5]


  Naming of the Infectious Disease; Epidemic Prevention and Control Top


In confronting the current COVID-19 pandemic, we suggest that institutions and individuals involved in forensic identification consider the following two points:

  1. The name of the infectious disease in this outbreak requires some consideration. According to the definition established by the World Health Organization, the disease caused by the novel coronavirus is officially named “COVID-19.” The International Committee on Taxonomy of Viruses has named the virus “SARS-CoV-2.” These international names should be used in the literature and in academic discussions. In forensic identification documents in China, however, we should use the Chinese name of this disease as described in the Notice on Printing and Distributing ICD Codes Related to COVID-19 Infection issued by the National Health Commission and National Healthcare Security Administration in China on February 13, 2020 (G.W.Y. H.[2020] No. 58). According to the injury level classification, this disease is called “2019 Coronavirus Disease,” “Novel Coronavirus Pneumonia,” “Novel Coronavirus Infection,” “Novel Coronavirus Pneumonia Clinical Diagnosis Case,” and “Suspected Novel Coronavirus Pneumonia Case.” We expect that forensic experts can accurately use each of these disease names in their identification documents
  2. The establishment should implement drills and occupational risk prevention and control plans for the work conducted by institutions that are engaged in forensic identification during pandemic. During this pandemic, the Fada Institute of Forensic Medicine and Science (China University of Political Science and Law) took the lead in formulating and implementing the Requirements on Protective Measures for the Identification During the Epidemics of COVID-19, Relevant Regulations on Internal Health Safety of Identification Sites During Epidemic Prevention and Control (Draft), and other normative documents and carried out targeted drills. These publications and activities can be used for reference by other institutions involved in forensic identification.



  Recommendation by Forensic Pathologists on Improving Pulmonary Obstruction of Patients Infected by Covid-19 Top


Autopsies performed by forensic pathologists on patients who died of COVID-19 have revealed the disease pathogenesis in terms of gross morphology and histopathology, especially the status of tissues and organs affected by the virus. These autopsies have made significant contributions to determine the cause of death (especially the direct cause of death, main cause of death, etc.) and to explain the mechanism of death.[6] According to autopsy findings, the lungs of patients with COVID-19 exhibit obvious mucinous inflammatory changes (Journal of Forensic Medicine, February 2020, Vol. 36, Issue 1). Airway mucus is mainly composed of epithelial goblet cells, submucosal gland secretions, and tissue leakage, and its viscoelasticity is mainly determined by secreted mucin. In the inflammatory state, in addition to an increase in mucus production and secretion, the composition and rheological properties of mucus may change. Such changes may include increased levels of glycosylation and sulfation, which increases the content of acidic glycoproteins in the mucus, leading to higher viscosity that is not conducive to the removal of mucus by the airway. Excessive mucus secretion causes and aggravates airflow obstruction within the respiratory tract. In addition, the mucus retained in the airway becomes a good medium for bacterial growth, which can result in secondary bacterial infection within the airway. The production of inflammatory factors, oxygen-free radicals, and neutrophil elastase promotes the high secretion of mucus and aggravate the infection, thereby forming a vicious circle, accelerating the progressive decline of lung function, and clinically manifesting as severe pulmonary obstruction. In such cases, regardless of the level of oxygen supplementation, the body's severe hypoxia state cannot be improved. This leads to a series of pathophysiological changes that progressively worsen the disease, and the patient may even die.

The systemic autopsy examinations of the patients who died of COVID-19 infection have provided a morphological basis for the severe hypoxia of patients infected by the COVID-19 virus.

For targeted treatment, we propose the following recommendations:

  1. Relief of the airway stenosis caused by airway spasm and edema, alteration of the rheological properties of mucus, enhancement of the clearance function of mucocilia, and other physical measures of improving sputum excretion


    • Drugs that can improve the physical and chemical properties of sputum: potassium iodide, guaiacol glyceryl ether, bromhexine, carbocisteine, deoxyribonuclease, chymotrypsin, bromelain, etc.
    • Relief of bronchospasm: aminophylline, ipratropium bromide, tiotropium bromide, etc.
    • Physical measures for the improvement of sputum excretion: humidification therapy to dilute the sputum, drug atomization therapy, postural drainage, and installation of a high-frequency oscillating device or bronchofiberscope to remove mucus plugs and improve sputum excretion.


  2. Therapeutic drugs to decrease mucus hypersecretion: protease inhibitors, cytokine antagonists, phosphodiesterase-4 inhibitors, tachykinin receptor antagonists, etc.
  3. Traditional Chinese medicine preparations.


    • Musk and bezoar pill: the musk and bezoar pill has the function of clearing heat and detoxifying. The musk and bezoar pill mainly treats acute upper respiratory tract infection, acute tonsillitis, and acute pharyngitis and is suitable for patients with light and medium pulmonary and gastric heat symptoms according to the syndrome differentiation of traditional Chinese medicine. The clinical use of this pill is safe and effective
    • Berberine: many studies have shown that berberine can negatively regulate airway inflammation and mucus hypersecretion, and its mechanism may be related to the inhibition of the inflammatory factors such as norepinephrine and nuclear factor kappa B, promotion of the anti-inflammatory factor interleukin-10, and downregulation of the mucoprotein Muc5ac
    • Pudilan antiphlogistic oral liquid: in a model of mice infected by the novel coronavirus, Pudilan significantly improved the pulmonary inflammatory lesions of infected mice.



  Recommendations for Identification Activities Related to Covid-19 Top


For forensic physicians who have intimate contact with the pathogen carriers of infectious diseases (living people or cadavers), the risk of infection is exponentially magnified.[7] According to our study of infectious diseases and other risk factors and based on the views of experts, we propose that the institutions and individuals involved in forensic identification should carry out work in the following five aspects: (1) strengthen education regarding infectious disease prevention and risk factors, improve the prevention awareness and response among professional forensic personnel, and enhance the scientific cognition of infectious diseases; (2) all institutions involved in forensic identification should formulate emergence plans for infectious disease outbreaks and conduct drills at appropriate times to immediately launch the contingency plan once the disease outbreak occurs; (3) improve current safety measurements including necessary protective medical supplies in institutions engaging in forensic identification; (4) abide by current laws and professional ethics, improve the awareness of individuals' right to protection and pay attention to protection of the legitimate rights and interests of the people concerned about infectious diseases; and (5) strengthen the research and public notification of the issues related to infectious diseases and other risk factors in forensic identification activities and the issues related to clinical and basic medicine.

Acknowledgments

This work was financially supported by the Strategic Research of Forensic Science and Legalization of Social Governance (Key Consulting Research Projects of Chinese Academy of Engineering, 2019-XZ-31). This article was originally released in Chinese language in Chinese Journal of Forensic Medicine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ghebreyesus TA, Swaminathan S. Scientists are sprinting to outpace the novel coronavirus. Lancet 2020;395:762-4.  Back to cited text no. 1
    
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Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020;395:470-3.  Back to cited text no. 2
    
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Peckham R. COVID-19 and the anti-lessons of history. Lancet 2020;395:850-2.  Back to cited text no. 3
    
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Wilson ML. Infectious diseases and the autopsy. Clin Infect Dis 2006;43:602-3.  Back to cited text no. 4
    
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Stephenson L, Byard RW. Issues in the handling of cases of tuberculosis in the mortuary. J Forensic Leg Med 2019;64:42-4.  Back to cited text no. 5
    
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Osborn M, Lucas S, Stewart R, Swift B, Youd E. Briefing on COVID-19: Autopsy Practice Relating to Possible Cases of COVID-19 (2019-nCov, Novel Coronavirus from China 2019/2020). The Royal College of Pathologists; 17 Feb 2020. Available from: https://www.rcpath.org/uploads/assets/d5e28baf-5789-4b0f-acecfe370eee6223/Briefing-on-COVID-19-autopsy-Feb-2020.pdf. [Last accessed on 2020 Feb 17].  Back to cited text no. 6
    
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Hostiuc S, Curca GC, Ceausu M, Rusu MC, Niculescu E, Dermengiu D. Infectious risks in autopsy practice. Rom J Leg Med 2011;19:183-8.  Back to cited text no. 7
    




 

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