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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 53-57

Forensic identification of cases with infectious diseases such as novel coronavirus pneumonia


1 “Initiative 2011”, Center of Cooperative Innovation for Judicial Civilization, Beijing, 100088; Key Laboratory of Evidence Law and Forensic Science (China University of Political Science and Law), Ministry of Education, Beijing; Center for Medical Law and Ethics, China University of Political Science and Law, Beijing, 100088, China
2 School of Law, China University of Political Science and Law, Beijing 100088, China

Date of Submission09-Jun-2020
Date of Decision09-Jun-2020
Date of Acceptance09-Jun-2020
Date of Web Publication09-Jul-2020

Correspondence Address:
Xin Liu
Key Laboratory of Department of Evidence Law Education, China University of Political Science and Law, Beijing 100088
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_36_20

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  Abstract 


Deaths or other legal disputes caused by novel coronavirus pneumonia (COVID-19) may require forensic pathological autopsy or forensic clinical identification. During daily forensic identification of cases in which individuals died of infectious diseases, forensic identification agencies and experts should be fully aware of the risk of infection when dissecting and examining such cadavers. Furthermore, forensic identification personnel should always adopt effective protective measures. As a novel infectious disease, research and information on COVID-19 are updated rapidly. Therefore, guidelines should be carefully selected for forensic identification. In addition to the above aspects, this paper has also discussed other common issues during the forensic autopsy of patients who died of infectious diseases, such as professional ethics, informed consent, insurance claims, and environmental protection.

Keywords: Forensic identification, infectious diseases, novel coronavirus pneumonia, occupational safety, pathological autopsy


How to cite this article:
Liu X, Liu W. Forensic identification of cases with infectious diseases such as novel coronavirus pneumonia. J Forensic Sci Med 2020;6:53-7

How to cite this URL:
Liu X, Liu W. Forensic identification of cases with infectious diseases such as novel coronavirus pneumonia. J Forensic Sci Med [serial online] 2020 [cited 2020 Oct 31];6:53-7. Available from: https://www.jfsmonline.com/text.asp?2020/6/2/53/289285




  Introduction Top


All matters involving people may lead to disputes, while addressing professional issues in any subject area may become the key to ascertaining the facts of a case. Therefore, when handling a dispute, it is inevitable for judicial organs to initiate a judicial appraisal process and assign or hire experts to conduct the appraisal. The novel coronavirus pneumonia (COVID-19) outbreak, which started in Wuhan at the end of 2019, but has since spread to the rest of the world, has now drawn the attention of people throughout both China and the world. Although China is the hardest hit area, multiple other countries and areas have also been heavily affected by the virus. Upon the end of the outbreak, it is expected that some people whose rights have been infringed or restricted or those who have been forced to fulfill certain obligations during the epidemic may resort to the law and seek judicial remedies to resolve disputes. The prevention, control, diagnosis, treatment, and rehabilitation of COVID-19 is not only a legal and political issue but also a professional and scientific issue. In cases where judicial organs initiate a judicial appraisal process that involves COVID-19, it remains unclear how forensic identification agencies and experts should perform the appraisal. To address this problem, this paper reviewed and summarized the correlation between COVID-19 and forensic identification.


  Overview of Covid-19 Top


In late December 2019, an outbreak of pneumonia cases with unidentified causes attracted the attention of the health department. On December 31, 2019, the Chinese Center for Disease Control and Prevention sent an epidemic response task force to Wuhan to investigate the outbreak, during which possible causes such as influenza, adenovirus, avian influenza, severe acute respiratory syndrome coronavirus (SARS-CoV), and Middle East respiratory syndrome coronavirus were excluded. Although the etiology and diagnosis of the disease remained unclear, the epidemiological investigation indicated that the infection was associated with the Wuhan Huanan Seafood Market. Consequently, on January 1, 2020, the local government closed the market and conducted thorough disinfection, followed by actively searching for cases and initiating emergency monitoring procedures.[1] On January 3, 2020, China notified the World Health Organization (WHO) of the outbreak.[2] As of February 18, 2020, there were a total of 74,280 confirmed COVID-19 cases, 5,248 suspected cases, and 1789 deaths in China, whereas other countries in the world reported 905 confirmed cases distributed in 29 countries. In contrast, during the SARS outbreak in China in 2003, as of August 7, 2003, there were only 8422 confirmed cases and 916 deaths (a mortality rate of almost 11%) involving 29 countries reported by the WHO on August 15, 2003.[3] Therefore, it is obvious that COVID-19 is more dangerous and infectious than SARS.

Regarding the name of the epidemic, during the early stage of the outbreak, the virus was temporarily named “novel coronavirus pneumonia,” or “NCP,” by members of the Novel Coronavirus Pneumonia Prevention and Control Committee of the State Council of the People's Republic of China. The WHO also initially designated the disease as “2019-nCoV,” which was later formally changed to “COVID-19” on February 11, 2020. Alternatively, after 2 weeks of discussion, ten members from the International Committee on Taxonomy of Viruses named the virus “SARS-CoV-2,” but this name remained controversial.[4] At present, the virus is still called “novel coronavirus pneumonia” in China.

Following the conclusion of the COVID-19 outbreak, if patients and their close relatives have disputes over deaths caused by COVID-19 or issues during the prevention, control, infection, diagnosis, and treatment of the disease, and decide to resort to judicial procedures, judicial organs that hear the case, as well as other relevant departments, will inevitably commence a judicial appraisal process that requires forensic pathological autopsy and forensic clinical identification. However, as the object that will be inspected, dissected, and tested carries SARS-CoV-2, a highly infectious virus, it is important for forensic identification agencies and personnel to implement protections during the appraisal.


  Improvement of Self Protection during Forensic Identification Top


Risk analysis of COVID-19 forensic identification

In forensic identification, experts and relevant personnel are commonly exposed to risks of infection when performing autopsy on patients with infectious diseases such as tuberculosis, AIDS, hepatitis B, and hepatitis C.[5],[6],[7] As an example, there was a case in which 14 of 22 participants of an autopsy were infected during the procedure.[8] In this case, the involved staff made several mistakes in infection control. Although some people may dismiss this report as a mere summary of inadequate infection-control practices, there were a number of factors that precluded or contributed to adequate infection control. First, there were too many people in the dissection room who were conducting teaching and learning activities. During the autopsy, the safety of everyone in the dissection room relied on the dissector. However, as there were 21 participants, the dissector could not be held responsible for all participants in the room. Therefore, for the autopsy of patients with infectious diseases, it is generally recommended that as few people as possible directly contact the cadaver before completing the dissection and fixing the tissue with formalin. Although adopting this practice may eliminate some teaching opportunities, most teaching activities can still be carried out after formalin fixation, as the appearances of organs and tissues do not change significantly after 1 or 2 days in formalin. Second, in this accident, the virus could be transmitted to the skin through droplets due to insufficient use of personal protective equipment during the autopsy. While it is relatively expensive to purchase and implement the provision of comprehensive personal protective equipment, the associated cost can be reduced by limiting the number of participants in the autopsy or by ensuring the proper use of personal protective equipment by the dissector and the participants. Third, the immunization statuses of those present at the autopsy were not clarified. The hospital is responsible for the collection and processing of autopsy participants' immunization information, while the medical school is responsible for the participating students. Last, the students who were engaged in the autopsy did not follow instructions or stay away from the dissection table, which led to their exposure to the virus through splashes. This was partly because it was infeasible for the dissector to monitor the actions of the large number of students who were present. In contrast, when there are fewer or even no students in the room, it is much easier to manage protection. Although having fewer attendees will jeopardize the teaching requirements as well as other factors, safety or quality should never be compromised.

Risk factors that may threaten the life and health of staff are commonly seen during forensic identification.[9] Forensic identification procedures, including forensic pathology and forensic clinical identification, or forensic toxicology and forensic evidence identification, inevitably require the inspection and examination of objects touched by the infectious patient or even his or her tissues, organs, body, and body contents. At present, there is no authoritative statement on thein vitro survival of the SARS-CoV-2 virus. Even when the outbreak is fully under control, sporadic cases are still possible. Therefore, identification agencies, experts, and relevant personnel who undertake the forensic identification task should be fully aware of the risks of infection. More specifically, staff should recognize all risks of virus contamination when receiving or delivering identification items from/to the clients, opening packages for identification, preprocessing or inspecting identification materials and samples, cleaning the test bench and the laboratory, as well as disposing of wastes once the procedure is completed.

Protection during forensic identification of COVID-19 cases

Specific protection measures should be implemented in strict accordance with COVID-19 regulations released by the National Health Commission of the People's Republic of China. The latest guideline is the “Protection of Medical Professionals” section in the “Technical Guidelines on the Prevention and Control of COVID-19 for Medical Establishments (1st Edition),”[10] which was released on January 22, 2020 by the National Health Commission. Personnel conducting autopsy and clinical identification should adopt protective measures such as droplet isolation, contact isolation, and air isolation. The following protective measures should be implemented for different situations:

  1. When in contact with the patient's blood, body fluids, secretions, feces, vomitus, and contaminated materials: wear clean gloves and wash hands after taking off the gloves
  2. When there is a risk of splashes of the patient's blood, body fluids, secretions, etc.: wear protective masks, goggles, and gowns
  3. When performing operations that may produce aerosol (such as tracheal intubation, noninvasive ventilation, tracheotomy, cardiopulmonary resuscitation, and manual ventilation and bronchoscopy before intubation) on suspected or confirmed patients: (1) Adopt air isolation measures; (2) Wear protective masks and check the airtightness; (3) Wear eye protections (such as goggles or face masks); (4) Wear protective gowns that prevent body fluid penetrations and gloves; (5) Operate in a well-ventilated room; and (6) Minimize the number of people in the room to only what is absolutely necessary to care for the patient
  4. The identification staff should also: (1) Only use protective equipment that meets relevant national standards; (2) Promptly replace protective equipment, such as surgical masks, protective masks, goggles, and gowns when it is contaminated by the patient's blood, body fluids, secretions, etc.; (3) Properly use protective equipment, wash hands before wearing gloves, and wash hands with flowing water immediately after taking off gloves or gowns; (4) Strictly follow sharp injury prevention measures; and (5) Clean and disinfect the medical instruments and appliances of each patient according to the “Regulation of Disinfection Technique in Healthcare Settings”
  5. When performing the autopsy of patients suspected to have died of COVID-19 or other respiratory infectious diseases, the dissection room should be well ventilated. Instead of central air conditioning or ventilation systems, natural ventilation or independent ventilation and air conditioning systems should be utilized.


Careful selection of identification methods

During forensic identification, multiple methods may be available for the identification of the subject. An autopsy is not always necessary, even for forensic pathological identification. Therefore, before conducting a forensic identification, the identification agency and the expert should carefully review the case records, understand the situation of the case from the client, and especially address key aspects such as case details, the focus of the disputes, and specific issues that the case handler would like to resolve. If the inspected person (or his or her cadaver) is confirmed or suspected to carry infectious diseases and a well-defined clinical diagnosis is available, pathological identification should prioritize the verification or elimination of the clinical diagnosis. In addition, postmortem biopsy can be used if necessary, which was adopted by pathologists for a patient in Beijing who died of COVID-19.[11] Furthermore, the inspection and autopsy of a person (or his or her cadaver) who is either confirmed or suspected to have infectious diseases should only be performed when sufficient and effective self-protection measures are in place. If possible, contactless methods, including remote video support, should be utilized. Relevant personnel should always prioritize their own safety and health during identification.


  Selection of Professional Guidelines for Identification Top


As a newly identified human pathogenic virus, COVID-19 is a recently discovered infectious disease. Therefore, technical specifications for COVID-19 have multiple versions and are frequently updated, which inevitably results in a substantial amount of outdated and wrong information that is still available. As a result, identification agencies and experts should pay special attention to the selection of guidelines as the identification basis.

Relevant laws, regulations, and regulatory documents

All countries in the world have relatively systematic laws and regulations on pathological autopsy.[12] Article 46 (2) of the “Law of the People's Republic of China on Prevention and Treatment of Infectious Diseases (2013 Amendment)” states that in order to identify the cause of the infectious disease, when necessary, medical institutions may perform autopsy and inspection of the cadavers of confirmed and suspected infectious disease cases following regulations of the Administrative Department of Public Health under the State Council. Prior to the autopsy, families of the deceased should be notified.

The “Provisions on Autopsy” divides autopsy procedures in China into three categories: ordinary autopsy, forensic autopsy, and pathological autopsy. Autopsies performed on the cadavers of patients died of COVID-19 belong to the pathological autopsy, which is the responsibility of medical institutions. However, autopsies performed on COVID-19 patients whose cause of death is controversial or involves legal issues instead belong to forensic autopsy.

Whether it is an ordinary, forensic, or pathological autopsy, it is important to strengthen protections to block the spread of the virus and prevent relevant personnel from being infected. Therefore, agencies and personnel who perform the autopsy, as well as other relevant staff, should strictly implement the regulations and requirements listed in the “Provisions on Autopsy of Cadavers of Patients with Infectious Diseases or with Suspected Infectious Diseases” (Decree No. 43 of the Ministry of Health, implemented on September 1, 2005), the “Guidelines on Disposal of Cadavers of Patients with COVID-19 (Trial)” (Letter No. 89 (2020) of the National Health and Family Planning Commission, released on February 1, 2020), and the “Notice on Regulating the Autopsy and Inspection of Cadavers of COVID-19 Patients by the Administrative Office of the National Health Commission” (Letter No. 105 (2020) of the National Health and Family Planning Commission, released on February 4, 2020).

Relevant technical guidelines and expert consensuses

Common clinical regulatory documents include guidelines, consensuses, clinical pathways, single disease management, textbooks, and instructions. In 2011, the Institute of Medicine of the United States of America defined guidelines as recommendations to provide patients with the best care based on systematic evidence and a balance of pros and cons of various interventions.[13] Alternatively, domestic scholars have proposed that clinical practical guidelines (CPG) refer to a series of systematic recommendations and instructions that can help clinicians and patients make appropriate decisions in specific clinical situations. These are usually the most authoritative clinical regulatory documents, as they are formulated and strictly controlled by professional associations.[14] Therefore, forensic identifications are often based on relevant guidelines. However, it should be noted that the formulation of CPG in China often lacks standardization, and the design of procedures and the selection of scientific results are often random. Furthermore, compared to guidelines, the formulation of expert consensuses is even less consistent. As a result, it is important to carefully choose guidelines for forensic identification. In terms of the identification of COVID-19 cases, the first trial edition of the “COVID-19 Diagnosis and Treatment Plan” was published by the National Health Commission on January 16, 2020. However, with the 6th ed.ition released on February 18, 2020, this document was updated five times within only 33 days, indicating that the medical community knows very little about the disease. Consequently, when applying technical guidelines and expert consensuses to the forensic identification of COVID-19 cases, it is important to pay attention to the agreement between the release date of the regulatory document and the implementation date of corresponding medical behaviors. Due to rapid updates of the diagnosis and treatment plan, failure of the medical staff to promptly implement the latest instructions on their publication cannot be simply regarded as “non-compliance with the diagnosis and treatment standards.”

Academic research data, literature, and other materials

Since SARS-CoV-2 is a newly discovered virus, people still know little about it, and associated information is constantly being updated. Therefore, professional journals that specialize in publishing academic research results have adopted an unconventional approach to publish the latest research outcomes. Most papers on COVID-19 were preprinted online without a peer review, with reports stating that the fastest publication only took 2 days between receiving the paper and publishing it online. Since a large number of research results are released online without a peer review or professional editing, there are inevitably mistakes in some of the papers, sometimes even resulting in the withdrawal of the publication. For forensic identification and especially forensic clinical identification, such information can only be used as a reference, but not as a basis for appraisal.


  Special Issues About Forensic Identification of Covid-19 Cases Top


Ethical issues in forensic identification

Forensic identification personnel should follow professional ethics standards during forensic identification.[15] These standards cover four perspectives: (1) The forensic identification itself, which should be performed with appropriate staff qualifications and methods; (2) The inspected person or cadaver, who should be respected and his or her privacy protected; (3) Close relatives of the inspected person or cadaver, who should be respected and their privacy protected; and (4) The public and the environment, where the public should be respected and their feelings taken care of and environmental protection and biosecurity measures should be strengthened. When performing identification on highly infectious cases such as confirmed or suspected COVID-19 cases, staff sometimes prioritize their self-protection over respect for the inspected person or cadaver and his or her close relatives. For example, when staff have a conversation with the inspected subject or his or her close relatives, inappropriate situations, approach, and language can all lead to communication difficulties. Alternatively, during autopsy, to promote air ventilation in the dissection room, doors and windows of the dissection room are kept open, and operations are performed under full exposure without any external covers. Even if the autopsy is carried out in an unmanned wilderness, it is necessary to dispose of the anatomical wastes carefully according to medical waste disposal regulations.

Informed consent of close relatives of the deceased

After a person's death, his or her personal rights should still be assured. Protecting the integrity of the cadaver is not only an important representation of the extension of personal rights, but also an essential part of condolences with consideration for the close relatives of the deceased. Except in situ ations where either criminal cases are involved, or national security and major public interests are endangered, the right of informed consent of the close relatives of the deceased should be respected. Relevant departments and identification agencies should explain to the subject the importance of autopsy and its procedures, the risks of the pathological autopsy, the extraction, fixation, slicing, and preservation of tissues and organs after the autopsy, and other details, and acquire an informed consent before conducting the autopsy. In addition, the right of informed consent of the close relatives of the deceased should be respected even when it is a postmortem autopsy.

Autopsy for insurance claims

For a long time, insurance companies have been relying on pathological autopsy as the basis for claims involving personal accidents, etc., whereas claims based on a pathological diagnosis of death cause without pathological autopsy are often rejected. The decline in autopsy rates in recent years is a worldwide issue.[5] In China, due to cultural traditions, families of the deceased often refuse autopsy to maintain the integrity of the cadaver, which has led to multiple disputes over insurance claims. During the severe outbreak of COVID-19, it is unrealistic and infeasible to perform pathological autopsies on all patients who have died of the virus. Although autopsies were performed on two patients in Wuhan who died of COVID-19, the purpose of the autopsy was not to identify the cause of the death, but rather to investigate the damage of the virus on the patients' tissues and organs, thereby exploring etiology and pathogenesis and on this basis develop better diagnosis and treatment plans. Therefore, when handling insurance claims of patients who were either suspected or confirmed to have died of COVID-19, decisions should be made primarily based on clinical symptoms, vital signs, and especially chest X-ray images. In addition, based on the trust principle, compensation should be approved according to the clinical diagnosis of the cause of death, even in the absence of a pathological autopsy.

Biosecurity and environmental protection during autopsy

The inappropriate disposal of wastes generated during and after the autopsy of infectious disease cases can lead to secondary contamination and even an outbreak of the disease. Even when the latter does not happen, the public may feel uncomfortable and even frightened upon realizing such accidents. Therefore, when carrying out autopsies of infectious disease cases, it is important for forensic identification agencies and experts to continuously think about environmental protection and biosecurity issues raised from the wastes and the autopsy itself, both during and after the autopsy. Disposal of wastes should be conducted in strict accordance with the requirements of the “Regulations on the Administration of Medical Wastes” and the “National Hazardous Medical Waste Inventory.” Medical wastes that carry pathogenic microorganisms and risk causing infectious disease transmissions should be categorized as Grade I Infectious Wastes, while other wastes should be categorized as either pathological waste, damaging waste, pharmaceutical waste, or chemical waste. Disposable medical devices refer to disposable instruments, equipment, appliances, and implant materials for use in humans that are listed in the “Regulation on the Administration of Medical Devices” and relevant supporting documents.[1] After the dissection has been completed, disposable medical devices should be destroyed. Then, they should be treated, packaged, and labeled as polluted wastes, and handed over to professional institutions for treatment together with other wastes (medical wastes).

Acknowledgments

This article was originally released in the Chinese language in the Chinese Journal of Forensic Medicine.

Financial support and sponsorship

Supported by the Key Project of National Social Science Foundation of China, “Research on Ethical Thinking and Legal Regulation of Medical Behaviors in China from the Perspective of Doctor-patient Relationship (No. 15AZD065).”

Conflicts of interest

There are no conflicts of interest.



 
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Introduction
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Improvement of S...
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