Management of the corpse with suspect, probable or confirmed COVID-19 respiratory infection – Italian interim recommendations for personnel potentially exposed to material from corpses, including body fluids, in morgue structures, during autopsy practice
The COVID-19 (Coronavirus Disease-19) is the most urgent health emergency worldwide and all professionals are called to give support in the diagnosis and treatment of patients affected by this disease. The Scientific Society of Hospital Legal Medicine of the National Health System (COMLAS) and the Italian Society of Anatomical Pathology and Cytology (SIAPEC) produced this document with the intent of offering a technical support to professional involved in the autoptic activities during the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) epidemic infection.
COVID-19 (Coronavirus Disease-19) is the most urgent health emergency worldwide and all professionals are called to give support in the diagnosis and treatment of patients affected by this disease.
The Scientific Society of Hospital Legal Medicine of the National Health System (COMLAS) and the Italian Society of Anatomical Pathology and Cytology (SIAPEC) produced this document with the intent of offering a technical support to professional involved in the autoptic activities during the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) epidemic infection.
Coronaviruses are a broad category of viruses known to cause diseases ranging from the common cold to Middle Eastern Respiratory Syndrome (MERS) and Acute Severe Respiratory Syndrome (SARS). Recently, a novel coronavirus (nCoV) was identified that had never previously been found in humans 1-3.
The viruses responsible for SARS include SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2); the disease caused by the new Coronavirus is called COVID-19 (Coronavirus Disease-19) and represents a cluster of pneumonia that has spread to China and other countries of the world since 31 December 2019 4-8.
Initial reports suggest that transmission occurs during close contact with an infected subject, mainly through respiratory droplets produced in the act of speaking, coughing or sneezing 9,10. Droplets can settle on the eyes, nose or mouth, as well as be inhaled by people nearby. At present, long-distance aerial transmission from person to person is unlikely.
Common signs of infection include fever, cough and breathing difficulties. In severe cases, the infection can cause pneumonia, severe acute respiratory syndrome, multi-organ dysfunction or failure, and death 11-16.
WHO, CDC and ECDC have provided clear details on measures to prevent the spread of the virus 17-21. Standard recommendations to prevent the spread of infection include regular hand washing, covering the mouth and nose when coughing or sneezing and avoiding close contact 22,23.
At the Italian level, the extra- and intra-hospital path of suspect or confirmed cases of COVID-19 and the indications relating to the use of personal protective equipment (PPE) by healthcare personnel are extensively defined 24-28.
In view of the limited scientific knowledge and evidence on SARS-CoV-2 infection, it is therefore considered appropriate to proceed systematically with the management of COVID-19 cases 29,30, whether they are suspect, probable or confirmed, accepted at the morgue. Hence the need to condense the available evidence on biological risk, individual protection and autopsy investigation with the aim of providing a practical guidance.
The recommendations expressed in this document have been developed to help healthcare professionals and morgue staff manage COVID-19 deaths by advising on possible risks and preventive measures. In the same way, indications will be provided about the post-mortem investigation of suspect, probable or confirmed cases of COVID-19.
Purpose and field of application
The classification of infectious hazards needs to be periodically reviewed and updated in light of global epidemiological trends. The categorization of infectious biological agents provides for the attribution to hazard groups (Hazard Group 1-4) based on the probability of causing disease in humans, the probability of spreading the infection in the community, the availability of prophylactic or therapeutic measures 31.
The Advisory Committee on Dangerous Pathogens (ACDP) in early 2020 established a provisional classification of SARS-CoV-2 as an HG3 pathogen (Hazard Group 3). In this regard, it should be emphasized that HG3 agents can cause serious diseases in humans and constitute a serious risk for professionals; the agent may spread in the community, but effective prophylactic or therapeutic measures are usually available. The risks for personnel operating in the morgue facilities, in most infections, are minimal when standard universal precautions for infection prevention are applied 32-35.
The purpose of the operating procedure is, therefore, to indicate how to manage the bodies of suspect or confirmed cases of COVID-19 in order to minimize the risk of environmental contamination and the contagion of personnel involved in the process. According to this perspective, the document is intended to recommend:
The present document is mainly aimed at staff serving in morgues (health professionals, trainees, as well as auxiliary, administrative and surveillance staff) and must be applied to every death from COVID-19, whether suspect, probable or confirmed.
Terms and definitions
COVID-19 CASE DEFINITION
The case definition is based on the information currently available and can be updated based on the evolution of the epidemiological situation and the scientific knowledge available 36.
The Circular issued by the Italian Ministry of Health on 09.03.2020 provides - in updating and replacement of the previous ones - the definition of suspect, probable and confirmed case 37.
Laboratory investigations for COVID-19 should be performed for suspect cases according to the following criteria, based on the updated WHO and ECDC definitions:
Any positivity found for common respiratory pathogens may not exclude co-infection with SARS-CoV-2 and therefore samples must be tested for this virus anyway.
Suspect case for which the result of the test carried out at the Reference Laboratories using specific Real Time PCR protocols for SARS-CoV-2 is doubtful or not conclusive, or, for which positivity to the pan-coronavirus test is confirmed.
Case with ascertained positivity for SARS-CoV-2 infection, regardless of the presence of clinical signs and symptoms.
DEFINITION OF CLOSE CONTACT
Close contact with a probable or confirmed case is defined as:
The epidemiological link can be established if contact is documented between the suspect case under consideration and a confirmed case within a period of 14 days before the onset of symptoms.
Hygiene precautions in the management of suspect, probable or confirmed case of COVID-19
In compliance with scientific evidence and the provisions of the Italian Ministry of Health, all health professionals involved in the management of suspect or documented cases of COVID-19 are required to adopt, in addition to standard safety measures, the necessary precautions to prevent the transmission of the virus 38,39.
Carry out antiseptic hand washing with alcoholic solution or antiseptic soap and water after each contact with the body.
In addition to the standard precautions, anyone who comes into contact with a suspect case of COVID-19 must strictly adhere to the contact precautions.
INDIVIDUAL PROTECTION MEASURES
PPE offers the highest possible protection against HG3 infectious agents. The morgue staff must use the following PPE in the coded manner for the different operational phases of body management (acceptance, custody, handling and autopsy) (Tab. I):
It must take place in the filter area according to the following steps:
The main stages of the dressing procedure are summarized below on the basis of the recommendations of the CDC on the correct use of personal protective equipment 42.
Correct use of facial filter
At the end of the procedures, in the filter areas, it is essential to:
The undressing procedure must take place in the filter area, taking care to avoid self-contamination, respecting the following sequence:
The main stages of undressing are illustrated below in two different sequences, in accordance with the recommendations of the CDC on the correct use of personal protective equipment 42.
Before leaving the autopsy rooms, carefully remove the PPE to avoid contamination and dispose of it in the appropriate containers.
Any reusable PPE (goggles, visors, respirators, etc.) must be properly cleaned, decontaminated and kept in view of subsequent use.
After the undressing procedure, scrub the hands with soap and water for at least 20 seconds. If the hands are not visibly dirty and there is no running water available, an alcoholic solution with a concentration of 60-95% can be used. However, in the event that the hands are visibly dirty, always scrub with soap and water before using any type of disinfectant.
Avoid contact of face, mouth, and eyes with gloved or unwashed hands 43.
Ensure the availability of hand hygiene devices in the immediate vicinity of the PPE removal area.
OPERATING PROCEDURE FOR THE MANAGEMENT OF THE CORPSE WITH SUSPECT, PROBABLE OR CONFIRMED DIAGNOSIS OF COVID-19
The proposed procedure is aimed at the safe management of the phases of acceptance, handling, custody, and discharge of the body with suspect, probable or confirmed diagnosis of COVID-19 44-47. The objective has been pursued by drawing up the following recommendations:
RECOMMENDATIONS FOR AUTOPSY INVESTIGATION IN CASES OF SUSPECT, PROBABLE OR CONFIRMED COVID-19
For the safe and effective performance of HG3 (Hazard Group 3) autopsy investigations, is required (Fig. 1):
The use of universal precautions effectively protects against most risks related to SARS-CoV-2 infection. Professionals have a duty to carry out risk assessment for each case in order to prevent actions that could put operators at risk.
Pre-autoptic risk assessment should include:
Information on the circumstances of the death is essential. In addition to information on the state of health and place of death, knowledge of any previous national and international trips, as well as laboratory data (positive and negative), is fundamental. It is important not to assume that the information acquired is accurate.
The criteria for the preliminary assessment of deaths and the definition of any cases are the same as those used to evaluate the possible risk of infection in living patients.
If after preliminary assessment it is believed that a death may be due to COVID-19, the subsequent investigations must be oriented towards confirmation of diagnosis and precise definition of the role of SARS-CoV-2 infection in the determinism of death (study of any pre-existing conditions and comorbidities capable of characterizing a condition of fragility of the subject). Judicial autopsies are an exception as any diagnostic activity depends on the prior consent of the Prosecutor.
For suspected or probable HG3 infection, preliminary nasopharyngeal and oropharyngeal swabs are recommended for diagnostic confirmation. In the event of a positive swab, especially if there is clinical, laboratory and radiological confirmation, the execution of the autopsy investigation is discretionary. In cases of swab positivity in which there is no clinical or radiological confirmation of the diagnosis, the study using post-mortem computed tomography (PMCT) is recommended in accordance with the availability and the care loads on the hospital structure; if a post-mortem radiological study is not possible, an autopsy should be performed. If the swab is negative, autopsy is mandatory.
The autopsy must concern all body districts and be oriented towards the search for significant findings for diagnosis 48-50. For this purpose, en bloc extraction of the cervical and thoracic organs is recommended in order to adequately define the respiratory pathological manifestations and facilitate sampling operations.
In general, the following measures are recommended for the safety of autopsy practice:
The team performing an autopsy at high infectious risk should ideally include an operating forensic pathologist/pathologist, a “clean” assistant forensic pathologist/pathologist and a technician. The assistant forensic pathologist/pathologist performs auxiliary tasks such as sample management.
Residents should be involved in autoptic activity only under the supervision of senior staff, but especially when they have demonstrated knowledge of the risks, awareness of protective measures and proven experience in autopsy practice 51,52; briefly, for HG3 cases, the Authors’ recommendation is to limit the involvement of residents in the most risky procedures such as evisceration.
From a structural point of view, performing HG3 autopsies requires effective ventilation in the autopsy room and the possibility to maintain an adequate distance in carrying out the different activities 53.
In accordance with the CDC indications, autopsies in cases of suspect or confirmed COVID-19 are always practicable as long as the conditions of maximum safety and infectious disease protection for operators and work environments can be guaranteed.
In particular, the CDC reports that “Autopsies on decedents with known or suspected COVID-19 should be conducted in Airborne Infection Isolation Rooms (AIIRs). These rooms are at negative pressure to surrounding areas, have a minimum of 6 air changes per hour (ACH) for existing structures and 12 ACH for renovated or new structures, and have air exhausted directly outside or through a HEPA filter. Doors to the room should be kept closed except during entry and egress. If an AIIR is not available, ensure the room is negative pressure with no air recirculation to adjacent spaces.
A portable HEPA recirculation unit could be placed in the room to provide further reduction in aerosols. Local airflow control (i.e., laminar flow systems) can be used to direct aerosols away from personnel. If use of an AIIR or HEPA unit is not possible, the procedure should be performed in the most protective environment possible. Air should never be returned to the building interior, but should be exhausted outdoors, away from areas of human traffic or gathering spaces and away from other air intake systems” 54-55.
Recommendations for the safe collection and transport of samples
The present document provides specific guidance for the collection and management of cadaveric specimens for the diagnostic in-depth of COVID-19. Similarly, recommendations are made for biosafety and infection control during specimen collection and handling 55,56.
In cases where an autopsy is performed, the collection of the following samples for SARS-CoV-2 research is recommended:
If the investigation ends with the cadaveric inspection, only the collection of swabs from the upper respiratory tract is recommended.
It is important to keep the SARS-CoV-2 samples separate from the samples taken for other microbiological and non-microbiological investigations.
The presence of health professionals in autopsy rooms should be limited to operators engaged in sampling. Since the collection of cadaveric samples does not induce coughing or sneezing, a negative pressure environment is not required.
Personnel must comply with the standard precautions previously described.
For the proper collection of a nasopharyngeal swab:
Proper execution of the oropharyngeal swab requires:
To perform an adequate lower respiratory tract swab:
Immediately after the procedure, place each of the swabs in a different sterile tube containing 2-3 ml of transport medium for subsequent storage in the refrigerator at 2-8°C before processing. Each container must be labeled indicating the identification number of the subject, the identification code of the sample, the type of sample and the date of collection of the same.
Safe preparation of specimens for transport involves:
Regarding the sampling of organs for formalin fixation 59,60, the collection of tissue samples with a size of 4-5 mm thickness is recommended. The volume of formalin used for fixation should be 3 times greater than the volume of the tissues. Use 10% buffered formalin for at least 48 hours to achieve optimal fixation. With respect to standard samples for histological investigations, particular care must be taken with a sampling of the trachea (proximal and distal) and lung (the hilar region with segmental and primary bronchi, as well as parenchyma representative of all the lobes of both lungs).
This sampling method finds its rationale in the viral tropism for the epithelia of the upper respiratory tract (in particular primary airways and segmental bronchi) which for this reason exhibit greater performance in molecular tests and immunohistochemical investigations 61,62.
Further sampling should be guided by the anamnesis, as well as by the autopsy findings and may include, for example, samples for bacteriological culture tests or toxicological investigations.
POST-PROCEDURAL PROPHYLACTIC RULES AND ENVIRONMENTAL DISINFECTION
Below are the general guidelines for cleaning and disposal of waste following a necropsy investigation of a suspect or confirmed case of COVID-19 63,64; it should be noted that at present the persistence time of SARS-CoV-2 on surfaces is uncertain 65,66.
At the end of autopsy investigations, the body must be positioned in a body bag and transported in a refrigerated room. Disinfect the outside of the body bag with a hospital disinfectant applied according to the manufacturer’s recommendations. It is also recommended to this phase to use suitable PPE by each operator involved in the movement and exit phases of the body.
In addition, following an autopsy on a subject with suspect or confirmed COVID-19, the following recommendations for disinfection of autopsy rooms should be applied:
Regarding environmental disinfection, the available evidence has shown that coronaviruses are effectively inactivated by adequate sanitization procedures that include the use of common hospital disinfectants, such as sodium hypochlorite (0.1-0.5%), ethanol (62-71%) or hydrogen peroxide (0.5%). There is currently no evidence to support a greater environmental survival or a lower sensitivity of SARS-CoV-2 to the aforementioned disinfectants 67.
Hard and non-porous surfaces can be cleaned and disinfected as previously described.
Handle with gloves and disinfect properly after use, equipment such as cameras, telephones and keyboards, as well as all objects that remain in the autopsy room.
Cleaning activities must be supervised and periodically checked to ensure that correct procedures are followed. Sanitation personnel must be properly trained and equipped with suitable PPE.
After cleaning and removing the PPE, wash the hands immediately. Avoid touching the face with gloved or unwashed hands.
Environmental disinfection must include cleaning with water and detergent soap on all vertical and horizontal surfaces, followed by disinfection with hospital disinfectants effective against SARS-CoV-2.
For environmental decontamination, it is necessary to use dedicated or disposable equipment. Reusable equipment must be decontaminated after use with a chlorine-based disinfectant. The use of special trolleys is strongly recommended, different from those used for cleaning common areas.
The instruments used for autopsies should be autoclaved or treated through chemical sterilizers.
MANAGEMENT OF ACCESS AND MOVEMENT OF VISITORS WITHIN THE FACILITY
Conclusively, it is necessary to formulate recommendations regarding the management of access and movement of visitors within the morgue area. Specifically, it is essential to establish procedures for monitoring, managing and informing all visitors:
Autopsy of inpatient subjects
Most of the autopsies performed by pathologists are requested by clinicians with the aim to clarify or confirm the causes of death of inpatients. By correlating clinical data with morpho-histological alterations of different organs and tissues the pathologists draw an epicrisis.
In the case of death for SARS-COV-2 the forefront diagnosis of the infection is based on the detection of the virus on nasal and oropharyngeal swabs with PCR technique. Lung involvement is paramount in SARS-CoV-2 infections and Computerized Tomography (CT) is the routine imaging modality to diagnose and monitor patients with SARS-COV-2 pneumonia 68. CT may assist in the early diagnosis of lung alterations typical of SARS-COV-2 during screening of patients with highly suspicious conditions, in particular patients with an initial negative RT-PCR screening result 69. The histopathological pattern of early SARS-COV-2 infection in the lung has been described 14 as an incidental finding on specimens obtained from patients operated for lung cancer, for whom the infection was not diagnosed at the time of surgery. The histological finding of advanced infection phase was reported on biopsy samples obtained from lung, liver and heart 15. The pathological characteristics of COVID-19 closely resemble those observed in SARS coronavirus and Middle Eastern respiratory syndrome (MERS) 16,70.
The above reported data suggest that in SARS-COV-2 infection the histological examination does not have a diagnostic role in the first instance but confirms the result of the laboratory test and of imaging.
AUTOPSY OF SUBJECTS WITH, SUSPECT, PROBABLE OR CONFIRMED SARS-COV-2 INFECTION
If an autopsy of inpatient subjects with, suspect, probable or confirmed SARS-COV-2 infection is requested to diagnose the cause of death, the procedure must be performed by the pathologists following the above reported operating procedures, including the procedure to collect tissue specimens (Fig. 2).
If the collection of tissue samples on the corpse of a subject with a full picture of infection or suspect of being infected with SARS-COV-2 is considered essential for disease diagnosis, an option is also to collect specimens from multiple organs (lung, liver, skeletal muscle) using core biopsy sampling, albeit with the limits of such procedures performed on cadaver (Fig. 2). The specimens must be immediately fixed in buffered formalin for no less than 48 hours.
The post-mortem biopsy sample collection must be: (a) requested on the advice of a multidisciplinary team that includes at least one clinician and one radiologist; (b) agreed with the reference pathologist; (c) the request must report patient personal data; outcome of swabs for COVID-19; clinical /anamnestic data and imaging report.
In the case of specific research protocols that require molecular or immunohistochemical analyses for which it is necessary to proceed with the collection of samples taken and stored in ways other than those indicated (for example, fresh or frozen samples) it is mandatory to agree with the regional reference center that will take care of the procedures for collecting, storing and transporting the material.
AUTOPSY ON PATIENTS WITHOUT APPARENT SARS-COV-2 INFECTION AND FOR CLINICAL REASONS INDEPENDENT OF PULMONARY PROBLEMS AND/OR COMPLICATIONS
In the event that a diagnostic autopsy is required for clinical reasons independent of lung pathology and/or complications in subjects who apparently do not have SARS-CoV-2 infection, it is recommended:
These precautions are necessary in order to preserve the safety of the health workers involved in the procedure and the quality of the diagnosis, responding to the clinical question by focusing on the real reasons for which the postmortem examination was requested. In addition, colleagues working in the Northern part of Italy in the areas with a greater spread of infection, who performed autopsy of patients with negative swab described histological changes consistent with those of lungs specimens obtained from autopsy of positive patients (necrosis microfoci, thrombosis of small vessels, hyperplasia of second-order pneumocytes, polynucleations and nuclear cytopathic alterations affecting endothelium and pneumocytes).
Thus, considering the current spread of the disease throughout the national territory, regardless of the hospital structure where the autopsy is carried out, but certainly in all those structures with a high number of positive COVID-19 inpatients, the execution of the diagnostic autopsy in any case must assume that the body is potentially infected and therefore take all appropriate precautionary measures as indicated in the section “Hygiene precautions in the management of suspect, probable or confirmed case of COVID-19” so as to avoid any risk of contagion, not necessarily from SARS-CoV-2. Consequently, all the procedures indicated for sanitizing the anatomical table and the sector environment must be followed after performing the autopsy.
Figures and tables
|Admission and Handling||- Contact with potentially infected material from corpses||- Disposable gloves (single pair) - Respiratory filter FFP2 - Goggles or protective visor - Disposable long-sleeved gown or waterproof suit - Disposable overshoes|
|Swab collection||- Contact with potentially infected material from corpses||- Disposable gloves (single pair) - Respiratory filter FFP2 - Goggles or protective visor - Disposable long-sleeved gown or waterproof suit - Disposable overshoes|
|Autopsy investigation||- Contact with potentially infected material from corpses - Sharp injuries - Production of splashes and aerosols||- Disposable headgear - Disposable gloves (double pair) - Cut-resistant protective gloves - Respiratory filter FFP3 - Goggles or protective visor - Disposable long-sleeved gown or waterproof suit - Disposable overshoes|
|Environmental disinfection||- Contact with potentially infected material from corpses - Production of splashes and aerosols||- Disposable gloves - Respiratory filter FFP3 - Goggles or protective visor - Disposable long-sleeved gown or waterproof suit - Disposable overshoes|