Role Of Autopsy in

COVID- 19 Pandemic
Prepared by: Yasmina Badr Abdel-Magid
 OUTLINE
Duties and responsibilities of the Procedures for Handling Dead
Forensic Practitioners and From COVID-19.
university forensic staff in 01
Egypt.

03 02

Medico-Legal Aspect of
Problems facing practice with
04 Emerging Issues during COVID-
19 Outbreaks.
deceased COVID-19 patients.
Duties and responsibilities of the Forensic
Practitioners in Egypt
Clinical Examination in criminal cases and
01
disability rating.

02 Forensic autopsy in suspected and criminal

cases.
Exhumation and autopsy in suspected
03
deaths.

04 Age Identification Examination of weapons,

clothes etc.

05 Clinical examination of the prisoners for

health release and for referral to hospitals.
Responsibilities Of the Forensic Medicine
University forensic staff:

Teaching forensic medicine, forensic sciences, toxicology, ethics and

01 law to undergraduate and postgraduate students’

Clinical examination and writing reports for medicolegal

cases referred from:
02 O Different department.
O Police.
O Prosecutor or court.

03 Medicolegal Laboratories Investigations

(chemical and molecular).
Medicolegal Consultancy reports on individual
04 demand or on legal referral/court order.
 Is The Deceased COVID-19 Patients
Infectious??

a forensic practitioner in Thailand was

reported to have been infected during
work.

it was stated later on that there was no

scientific proof of infection taking place
during autopsy.
 Infectivity of deceased COVID-19 patients Plenzig et al,2021
Aim: to investigate the infectivity and its duration of deceased Covid- 19.

Method: Conclusion:
● Corpses of deceased COVID-19 patients have
● Four SARS-CoV-2 infected deceased patients
to be considered potentially infective for more
were subjected to medicolegal autopsy. Post
than 2 weeks post mortem under typical
mortem intervals (PM of 1, 4,9 and 17 days).
● cooling conditions.
Tissue samples for histopathological
● The infectivity is mainly dependent on the
examination.
● time interval between initial disease
toxicological analysis.
● symptoms and the occurrence of death as well
swabs and organ samples for the detection of
as the viral load and may be present even after
SARS-CoV-2 ribonucleic acid (RNA).
the onset of decay.
Protocols for Management of Deaths in
Pandemics
 Technical Recommendations for Body Handlers:
For autopsies, it is recommended to use the following
personal protective equipment:
● double surgical gloves.
● a fluid-resistant or non-permeable protective dress.
● a water-resistant apron and goggles or a face protector.
● FFP3 masks or a single-use N-95 (or higher) breathing
mask accredited by the National Institute of Occupational
Safety and Health.
 Special considerations for temporary conservation
areas:
• Disinfection of body bags upon arrival at temporary
conservation area.
• Place the original body bag containing the remains inside
a second bag.
• Disinfection of the outer bag following the identification
of the remains or after the completion of post-mortem
procedures.
• Records of all human remains movements within the
temporary conservation area and final preservation.
 Special considerations relating to the final preservation of the
remains, or their delivery to relatives

• If human remains are to be permanently preserved/buried at another location, they

should be placed inside a second external body bag (in case that human remains are

placed inside two bags in advance, the outer bag should be removed and another new

use should be cleared.

• The exterior is well cleared before the remains are removed from the site.
 Special considerations relating to the final preservation of the
remains, or their delivery to relatives:

• The cremation of unidentified human remains should be avoided and buried in individual
graves is the best way to preserve them once and for all.
• care must be taken to ensure that decomposing human remains do not leak so as not to
contaminate groundwater. Burying bodies in their body bags regardless of the use of shrouds.
• The personal belongings of the deceased infected may pose a potential risk of transmission of
contamination. Decontamination of these should be taken before being handed over to relatives
of the deceased.
Procedure for Handling Dead From
COVID- 19 Egyptian MOHP
 From ward to Morgue
The same procedures and precautions that were applied during

life must be taken, including:

• Moving away from the body for a distance of more than a

meter,

• lifting the dead with the bedsheet, and transferring it to

the hospital morgue, on a trolley that can be cleaned and

disinfected, taking into account wearing Personal

Protective Equipment (PPE).

 Washing and Shrouding Procedures:
• The person on the wash should wear PPE, (a highly-efficient respiratory mask,

a clean glove that covers the wrist, a thick mantle that covers the arms and

chest and extends to the bottom of the knee, goggles, a head cover, plastic boot

and a neck collar).

• Only near relatives can join during washing, and in case of necessity they must

keep away from the corpse for a distance of more than a meter, and wear PPE,

• Parts of the body from which secretions occur must (nose, mouth anus urethra,

vagina) be covered with impermeable dressings.

 Procedures For Transporting the Body After Washing and
Shrouding the Dead Vehicle:

- Not The Ambulance.

- The corpse must be moved inside the non-permeable bag for liquids,

with a sign of the RISK OF INFECTION being placed on it, and this should be

clarified by official papers, adding that it must be taken into account that the corpse

must be inside a closed box that can be cleaned and disinfected, bearing in mind

that it should not be opened except in the vault.

 Burial Procedures:
• When opening the box to transport the corpse inside the cemetery, all

protective measures should be applied by the burrier.

• The presence of the least number possible when the corpse enters the cemetery.

• The full commitment to washing hands with alcohol when available to

everyone who deals with the deceased, and cleaning and disinfection of all

surfaces that have come into contact with the corpse using disinfectants

approved by the Ministry of Health, such as liquid chlorine (conc, 5% &

dilution 1:9).
If there is a suspension of infection a
swab should be taken first and the
above procedures were
implemented.
Problems Facing Practice with Deceased
COVID-19 Patients in Egypt
Stigmatization
autopsy
Death Certificate and cause of death.
1. Stigmatization:

- Social Stigma: discrimination & devaluation by others.

2. Death certificate:
- Death notification is followed by death certificate.
3. Hospital Autopsy:

- Post-mortem examinations (autopsies) are the gold standard for the elucidation of
the underlying pathophysiology of disease.

"In patients dying with SARS-CoV-2 infection, the autopsies confirm laboratory
and radiological findings and can contribute to an accurate diagnosis and to a
better understanding of mechanisms of the disease."
 Recommended Postmortem Specimens for collection:

- The following factors should be considered when determining it for a

deceased known or suspected COVID-19 case:

• medicolegal jurisdiction.

• environmental controls.

• availability of recommended per protective equipment (PPE).

• family and cultural wishes.

If an autopsy is performed for a suspected COVID-19 case, collection of the
following postmortem specimens is recommended

● Postmortem swab specimens for COVID-19 testing:

o Upper respiratory tract swab: Nasopharyngeal Swab (NP swab)

o Lower respiratory tract swab: Lung swab from each lung

● Separate swab specimens for testing of other respiratory pathogens and other postmortem

testing as indicated

● Formalin-fixed autopsy tissues from lung upper away, and other major organs
If an autopsy is NOT performed for a suspected COVID-19 case, collection
of the following postmortem specimens is recommended:

● Postmortem Nasopharyngeal Swab (NP swab) specimen for COVID-19 testing.

● Separate NP swab for testing of other respiratory pathogens.

If an autopsy is performed for a confirmed COVID-19 case, collection of the
following postmortem specimens should be considered:

● Postmortem swab specimens for testing of other respiratory pathogens.

● Other postmortem microbiologic and infectious disease testing, as indicated

● Formalin-fixed autopsy tissues from lung upper airway, and other major organs.
 procedures are consistent with existing guidelines for safe work
practices in the autopsy:
● Use of an oscillating bone saw should be avoided for known or

suspected COVID-19 cases. Consider using hand shears as an Limit

5
PEOPLE
alternative cutting tool. If an oscillating saw is used, attach a

vacuum shroud to contain aerosols.

● Allow only one person to cut at a given time.

● Limit the number of personnel working in the autopsy suite at any

given time to the minimum number of people necessary to safely

conduct the autopsy.

 procedures are consistent with existing guidelines for safe work
practices in the autopsy:

● Use a biosafety cabinet for the handling and examination of smaller specimens and

other containment equipment whenever possible.

● Use caution when handling needles or other sharps, and dispose of contaminated

sharps in puncture-proof, labeled, closable sharps containers.

● A logbook including names, dates, and activities of all workers participating in the

postmortem and cleaning of the autopsy suite should be kept to assist in future follow

up, if necessary. Include custodian staff entering after hours or during the day.
 Storage of Postmortem specimens:
- Swab Specimens Store specimens at 2-8°C for up to 72 hours after collection. If a

delay in testing or shipping is expected, store specimens at -70°C or below.

 Cleaning and waste disposal recommendations.

 Transportation of human remains.

Autopsy
Findings
 Lungs in nearly all cases showed:

o Diffuse alveolar damage. (2nd cause of death)

o typical microscopic evidence of clinical acute respiratory distress syndrome (ARDS),

with most cases showing fibrin (a fibrous, non-globular protein involved in the clotting

of blood) and/or platelet thrombi, or clots, to varying extents.

o Saddle & shower emboli.

o Pneumonia. (3rd cause of death)

o Pulmonary thromboembolism (most common cause of death).

 Blood:

o blood clots in multiple other organ systems—most notably the brain, kidney, and liver

reflects endothelial damage as an underlying process, which correlate with the

activation of the coagulation cascade and persistent elevation of blood markers of

inflammation.
 Brains:

o showed a surprising scarcity of inflammation, with only a few cases showing small foci

of chronic inflammation.

o microthrombi with small and patchy evidence of tissue death caused by blockage of

blood vessels in both peripheral and deep parts of the brain.

o These small microinfarcts may explain some of the psychological changes seen in some

COVID-19 positive patients.

 Medico-Legal Aspect of Emerging
Issues during COVID- 19 Outbreaks
There is no doubt that the accelerating and increasing spread of
the COVID -19 pandemic has led to overriding a lot of axioms
on which the medical practice was based from years ago, that led
to controversy and the emergence of controversial medico-legal
issues.
Medical
Ethics
Issues:
1. It is noticed that the attitude and behavior of the patients of COVID-19 and their
relatives are varied wherever some people have panic for the fear of infection spread
while others feel a shame trying to cover up the infected cases. Thus, the physicians
face a challenge during the examination of the COVID -19 cases.
2. Medico-legally, it is known that confidentiality and maintaining professional
secrecy are main principles in the relationship between physician and patient. But
there is a medicolegal exception for these medical ethics rules in the cases of COVID
-19 infection because it is permitted for the physician to disclose the professional
secret and notify the public authority and the relatives about the condition of the
patient for the quarantine to prevent the spread of infection.
3. The frenzied and accelerated attempts to secure a coronavirus vaccine without
being bound by the scientific steps followed in such researches and without being
bound by the necessary and enough clinical trials are considered a breach of the
scientific research ethics.
4. The allocation of scarce healthcare resources and the equivalence of withholding
and withdrawing medical interventions is one of the ethical dilemmas that emerged
during the COVID-19 pandemic.

Furthermore, there is an ethical strategy in epidemics, emergencies, and disasters

that is recommended and authorized by WHO that includes triage criteria based on:
- saving the greatest number of people.
- protecting the most vulnerable.
- equal access.
- the priority for the most important.
- first come, first served.
 Medical
Responsibilit
y and
Malpractice
Issues
1- COVID -19 patients has a right to be examined and diagnosed by a physician.
Thus, it is not the right of the physician to refuse the examination of a COVID- 19
patient because of his fear to be infected because it is an emergency case. So, the
physician should do his duty by following the necessary precautions and biosafety
measures.
2. it is also the right of the patient of COVID -19 to receive a scientifically recognized
treatment with proven efficacy and known of its potential side effects. Unfortunately,
this treatment is not available until now. However, the commitment of the physicians
to apply some therapeutic protocols that are authorized via some official health
agencies such as WHO is not considered malpractice in the COVID-19 outbreak.
3. using of other herbal medications or that is called alternative medicine that is
used by non-professionals is considered medical malpractice.

4. using any unauthorized drug or therapy in treating the cases of COVID-19 is also
considered medical malpractice.

5. The consent of the patient is not necessary in COVID-19 infection cases

because it is considered an emergency case.

6. In the time of the pandemic, any negligent action may spread COVID-19 infection
such as breach of biosafety measures in the hospitals is considered medical
negligence.
 Autopsy
Conduction
of COVID-
19 Cases
1. If there is an urgent medico-legal necessity to conduct postmortem examination and
autopsy for COVID -19 cases, the forensic expert should remind himself how to
apply biosafety measures.
2. the first target of conducting an autopsy in a forensic case is the identification of the
cause of death. Thus, it should identify the pathogenesis process and the possible
postmortem findings in these cases.

- So, if this forensic case is suspected or confirmed COVID-19 infection, it should

conduct an appropriate autopsy by the forensic expert because this is a legal duty and
then he can’t refuse or withdraw.
3. In addition, the available data about the pathological findings of COVID -19
infections is limited, so it should take diagnostic samples to verify the infection.
4. Until now, there are not specific or pathognomonic findings for COVID-19
infection; So, the role of the forensic expert is not to conduct a legal autopsy in the
criminal cases only, but via sharing the pathological findings of comprehensive
postmortem examination of COVID-19 cases to compensate shortcoming of the
available information about the pathogenesis mechanism of this infection showing the
role of other risk factors and other affected organs wherein COVID-19 is not restricted
to respiratory system only.
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