THE RISK OF DOING AN AUTOPSY AND

HIGH-RISK AUTOPSIES
(Ivan Fernandez Vega. Central University Hospital of Asturias)

THE RISK OF DOING AN AUTOPSY

While performing autopsies, pathologists, technicians and junior staff are exposed to various
hazards, and those have been classified into 7 categories:

1) Falls.

2) Cuts with instruments.

3) Electric shocks

4) Overexertion.

5) Exposure to chemical agents.

6) Exposure to ionizing radiation.

7) Exposure to biological agents (High-risk autopsy). There are many biological risks with
different consequences, and some of them are life-threatening. Among the first known
cases of fatal infections during autopsies, there is that case of the Viennese physician
Kollestcka, who died after cutting a hand from a patient who suffered from streptococcal
septicemia. Currently, we are exposed to different pathogens such as mycobacterium
tuberculosis, human immunodeficiency virus, hepatitis...Therefore, it is absolutely
necessary that autopsy rooms are built following the right guidelines, and that the
personnel involved in this task, know and correctly apply the mandatory preventive
measures.

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 1) FALLS

Falls from the same level of height are mainly caused by wet floors. Floors in autopsy rooms
must be built with non-slip materials, and they should facilitate drainage through a slight slope
leading fluid (mainly blood and water) to a central hole drain. It is also desirable to wear anti-
slippery shoes. When the room does not meet these features, you can instead place sheets or
towels around the table to keep the floor dry.

Pay attention in the presence of wires lying on the floor from electrical equipment because it is
another additional risk factor. Besides, the use of not adjustable in height autopsy tables, which
forces shorter people to use platforms, hence increasing the risk of falls.

2) CUTS WITH INSTRUMENTS

Once we make contact between the cutting tool and the deceased, we may suffer two types of
damage: wounds caused by the sharp object and the infection disease. The biological risk
makes it necessary to have extreme precautions when manipulating hand cutting tools,
especially when removing the disposable cutting parts before putting them into special
containers.

Concerning electric saws, besides biological risk, wounds caused by their use are usually quite
considerable. To minimize this risk, it is highly recommended the use of specific saws. To ensure
that the saw is safe enough, within European Union they must meet special requirements (with
CE mark).

3) ELECTRICAL CONTACTS

Any damaged electrical wire could cause a shock after touching it, or by putting them in touch
with the metal autopsy table or with the wet floor. Another source of possible electrical hazard is
when removing a pacemaker or an implantable cardioverter defibrillator (ICD).

4) OVEREXERTION

It is mostly produced when mobilizing the patient body. This risk usually involves autopsy
assistants. To prevent it, the body must be handled mechanically, minimizing manual
mobilization. There are cranes or "transfer systems” to facilitate this tasks.

5) EXPOSURE TO CHEMICAL AGENTS

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Formaldehyde is the principal one and handling it expose you to the following risks:

- Toxicity due to inhalation, ingestion and skin contact (mucosal irritation).

- Burns.

- Skin irritation

- Highly flammable.

- Carcinogenic effect. It has recently been reclassified by the International Agency for Research
on Cancer (IARC) from group 2A (probably carcinogenic to humans) to group 1 (carcinogenic
to humans). The Spanish legislation recommends, as a preventive measure for carcinogens, to
replace them by less dangerous compounds. When this is not feasible, as it is in the present
case, exposure should be reduced to levels as low as possible: keep the formaldehyde in closed
containers, wear masks with appropriate filters etc.

6) EXPOSURE TO IONIZING RADIATION AGENTS

It occurs when a patient underwent a treatment with internal radiation radioactive implants, such
as those used in some cancer therapies (brachytherapy seeds). To prevent this risk, it is better
to consult the patient’s medical services for advice before performing autopsy.

7) EXPOSURE TO BIOLOGICAL AGENTS

During the autopsy, pathologists and assistants might be exposed to many microorganisms that
can be transmitted in different ways. The most important ones are direct inoculation, skin or
contact with the mucosa, aerosol inhalation etc. Regarding their level of risk, these biological
agents are classified into four groups according to their infectious risk, the risk of spreading to the
community and prophylaxis or early treatment that can be applied (Table 1).

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Table 1: Classification of the risk groups.

RISK INFECTIOUS RISK RISK OF PROPAGATION TO PROPHYLAXIS OR EARLY TREATMENT

GROUP THE COMMUNITY

1 Rare that causes disease No Unnecessary

2 They can cause illness and Unlikely Generally possible

be a danger to workers

3 It can cause serious illness Probable Generally possible

and they can pose a
serious a danger for
workers

4 They produce a serious High Unknown today

illness and they pose a
serious danger for the
worker

Considering the basic principle of treating all patients as potentially infectious, pathologists and
their assistants should always take measures to avoid infection by any of the possible routes of
transmission, that is to say, a biosafety level 3 (BSL-3) of protection. A biosafety level 2 (BSL-2)
provides personal protection against most pathogens that are transmitted through bloodstream.
Furthermore, a biosafety level 3 (BSL-3) protection is achieved to prevent infection of biological
agents by inhalation of contaminated aerosols (such as Mycobacterium tuberculosis, etc.). If the
patient has a group 4 microorganism, autopsy should be avoided in most of the cases.

a) Structural measures for biosafety level 3.

Signs of restricted access to the work area only to the designated personnel.

It is also advisable that main doors at dissection room have a translucent window to see the
occupants from the outside.

The area between dirty zones and clean zones should have the dressing room with showers,
toilets and laundry and waste containers.

Extracted air from the autopsy room should be filtered using the right filters so that the air goes
out directly to the outside without being recirculated.

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The dissection room should have negative air pressure in relation to adjacent areas of the
autopsy room.

Specific protocols for disinfection should be applied after every autopsy procedure. Sometimes,
dissection room could be sealed for disinfection. Therefore, work surfaces should be resistant to
acids, alkalis, solvents and disinfectants. Besides, surfaces of desks, floors, ceiling and walls
should be water resistant and easy to clean.

b) Personal protective equipment:

All material used should be disposable. Autopsy personnel should wear a full-body clothing,
plastic screen, masks, gloves, boots, pants etc. In addition, they should wear protective gloves
against punctures. Surgical masks should be considered sufficient to protect the worker for
splash in the nasal and oral mucosa. Concerning boots, they should be closed, waterproof, high,
anti-slippery, easy to clean and resistant to disinfectants.

c) Others: Right hygienic measures. Decrease aerosolization. Precautions about

sharp objects. Common sense.

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HIGH-RISK AUTOPSIES

Performing autopsies poses the highest risk for any health professional. After death, some
microorganisms are released. Moreover, reticuloendothelial system or even blood brain barrier
no longer work properly so microorganisms are able to disseminate through the whole body.
The most frequent high-risk autopsies are due to the following infection diseases: HIV (HIV),
hepatitis B, C, D and E, tuberculosis, COVID-19 and Creutzfeldt-Jakob´s disease.

The infection chain from a host to a healthy individual is shaped basically as follows:

- Infectious agent

- Reservoir: The reservoir of an infectious agent is the habitat in which the agent normally lives,
grows, and multiplies. In this case is the deceased body.

- Portal of exit and modes of transmission. An infectious agent may be transmitted from its natural
reservoir to a susceptible host in different ways. During an autopsy procedure, the main modes
of transmission is a direct transmission either by direct contact or by droplet spread such as:

i) Autoinoculation: punctures with contaminated needles with blood or biological fluids.

ii) Splashed with blood or other biological fluids in the mucosa (eyes, nose and mouth)
or in the skin with open wounds or dermatitis, or in mucosa.

iii) Inhalation or ingestion of the microorganisms

- Portal of entry / Infective Dose

- Host susceptibility.

1) HEPATITIS
Li et al and Plessis et al have reported a prevalence rate of B hepatitis between 23% and 8%,
respectively in forensic autopsies,. This virus is 100 times more transmissible than AIDS. There
is an available vaccine. Hepatitis B virus (HBV) is quite resistant to the environment. Indeed,
HBV in human plasma is able to retain infectivity after one week in dry conditions and being
exposed to the environment. On the other hand, the transmission of the hepatitis C virus is mostly
associated with percutaneous inoculation with infected blood from the decease body. The
associated personnel in the postmortem examination is among the personnel at risk due to the
punctures and cuts suffered when handling infected organs.

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 2) ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)

Compared with HBV and HCV, AIDS developed by the human immunodeficiency virus (HIV)
has low infectivity. The risk of infection due to needlestick injuries is estimated at between 0.3%
and 0.5%. The virus does not survive for long periods of time in dryness conditions. However,
postponing an autopsy of a HIV positive deceased does not eliminate the risk of HIV
contamination. Thus, this virus should be considered infectious for at the least two weeks after
the death of the infected individual.

3) TUBERCULOSIS (TB)

Almost a third of the world population is infected with Mycobacterium tuberculosis. Is the most
common cause of death from an infectious disease by a single organism in the general
population but also in people infected with HIV.

Autopsy personnel usually get infected by inhalation of aerosol particles creating after using
oscillating saw. Indeed, autopsies are quite efficient method of transmitting tuberculosis from the
deceased body to the staff present in the autopsy room. Thus, one study has reported that 8 out
of 35 negative Mantoux medical students became positive after indirectly exposing themselves
for 1 hour, as observers during an autopsy infected by TB. The risk of infection does not varies
with autopsy table distance. Besides, exposure for 10 minutes in an autopsy room resulted in
the transmission of TB in one medical student. Moreover, formalin-fixed tissues have still the
potential of transmitting infectious aerosols with TB bacillus.

4) CREUTZFELD-JACOB DISEASE (CJD)

Although there is no evidence of transmission by aerosols, the lack of effective treatment against
this disease demand us to take maximum precautions when handling infected material. To the
best of our knowledge, there are not documented cases of infection by Creutzfeldt-Jackob in an
autopsy room. However normal disinfection methods are ineffective, and infectivity is maintained
even in formalin-fixed paraffin embedded tissue.

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Translated and revised by Iván Fernández-Vega, M.D., PhD; and Elena Avanzas, PhD.