The College of American Pathologists position on autopsies during COVID-19

This post is written from my perspective of around ten thousand autopsies performed as an anatomic pathologist (Russia, Sant-Petersburg), pathologists’ assistant and morgue attendant (both in Chicago). Although the immediate trigger for this post were two articles about autopsies in CAPTODAY magazine’s May and June issues, other materials also added some details to my assessment of the autopsy performance situation during the COVID-19 epidemic in the USA.

The number of performed autopsies in USA shrinks every year by concentrating on rare unclear medical situations. Autopsies are done more as public service by relatives’ request or forensic examination, although the role of autopsies in establishment of current pathology knowledge is indisputable. For understandable reason, anatomic pathology operates without clinical work urgency and with some specific methods on its disposal.  In this regard, the importance of autopsies as educational diagnostic tool should increase during COVID-19 epidemic.

Autopsy performance regulations

In reality, postmortem examination, or autopsies, became a victim of the scare which came from China and Italy on the onset of the COVID-19 pandemic. Watching on TV health care workers in China dressed like astronauts before the takeoff and coffins piles in Bergamo, Italy, autopsy performance has been stopped due to Occupational Safety and Health Administration’s (OSHA) recommendation. For hospital’s administration, the OSHA recommendation is the order.

As a public service organization, OSHA issues recommendations based on information provided by professionals in the field. In the case of autopsies, in ideal, we can expect a reciprocal interaction between Center Disease Control and Prevention (CDC), College of American Pathologists (CAP), and OSHA. CDC provides necessary general health and nosology information, including regarding infectious diseases. CAP determines diagnostic and other medical approaches, while OSHA issues necessary correlation for safety performances (Diagram 1).


Diagram 1. Reciprocal interactions between CDC, CAP, and OSHA in autopsy regulations.

Under conditions of the epidemic, the role of CDC becomes dominated. CDC should provide reliable information to both OSHA and CAP, assuming the entire anatomic pathology group in the USA under the CAP moniker.            

However, the epidemic caught CDC flat-footed.  The confusing and ambiguous CDC’ and also Dr. Fauci’ (National Infection and Allergy Institute) statements are well-known. They are discussed in different posts of the Blog. The updated material CDC regarding autopsies is presented in the CDC’s Autopsy Guidance for COVID-19 post with some comments.

The College of American Pathologist’s position

What about CAP and hospitals’ pathologists? Already mentioned two articles in CAPTODAY (May and June issues) can shed some light to the pathologists’ attitude toward autopsy performance. It would be right to distinguish CAP and hospitals pathologists’ approaches. The CAP ‘s position was to hide behind CDC and OSHA limitations. All CAP’s documents only repeat the CDC’s provisions.  In CAPTODAY June issue, from the President’s Desk Getting through the pandemic column the CAP’s president Dr. Patrick Godbey haven’t mentioned postmortem examination at all.

The CDC’s guidelines include details of submission to histology (for example thickness of section) that means the pathology participation in the document. But on the crucial issue of autopsy performance, CAP preferred to follow CDC’s and OSHA’s recommendations for autopsy limitations.

The CAP’s Autopsy Commission Committee’s Amended COVID-19 Autopsy Guideline on May 5, 2020 is remarkable as a masterpiece of walking between streams of water. On one hand criticizing the CDC’s ambiguity, on the other hand following them instead of expressing the position and defending it.

 Dr. Williamson, a member CAP’s Autopsy Committee, was involved in listserv discussions which started in late March. His position as “We can’t and shouldn’t autopsy every COVID-19 death” is right but his next statement is disputable: “That’s an impossibility and it’s dangerous.” Why dangerous?  The CAP’s Autopsy Committee were proud that some pathology departments have met CDC’s engineering requirements without questioning why they were imposed. “OSHA guidance was ill- informed” he stated, but CAP’s Autopsy Committee should inform OSHA which is a bureaucratic organization. Doctors are equipped with education.  Pathologists are obliged to challenge the OSHA’s unsubstantiated limitations instead of hiding in listserv discussions and losing precious time. Epidemic is a fire, and pathologists must be a part of the firemen.

Until today, many hospitals, for example in Chicago, do not perform autopsies on coronavirus positive decedents. These cases are sent to the Medical Examiner office due to the absence of negative pressure morgue rooms.

Autopsy criminalization

It looks that CAP accepted regular pathologist’s secondary role in handling COVID-19 related cases after forensic services. CDC’s emphasized an autopsy as medicolegal event (see the CDC’s Autopsy Guidance for COVID-19 post). Why? What is criminal in COVID-19? It is a regular infectious disease like influenza or myocardial infarct unless it is suspected a foul play or relatives requested an autopsy. The National Board of Medical Examiners has taken the lead in postmortem examinations in COVID-19. But autopsy pathology is different from forensics. By training and resources hospital’s pathologists are (or should be) more equipped for natural disease pathology autopsies which are different from forensics by their predominately educational goal.

The previous clinicians’ habit to attend autopsies is now considered old-fashioned. However, the Greek word autopsia stems from the act of seeing with one’s own eyes. It appears that an opportunity would be very useful for clinicians to visualize the pathology process, which often is puzzling to them. In this regard, the CDC’s recommendation of the minimization of autopsy attendance is wrong. What is the CAP’s position on this issue?

Personal Protective Equipment (PPE)

Nobody would doubt that PPE must be used during every autopsy, especially on an infectious disease case.  OSHA’s requirements are reasonable (see COVID-19 Protective equipment post). However, some practices go too far in protective equipment. What they are afraid of? There is not a rational explanation.

The photo taken from CAPTODAY shows a pathologist and a morgue attendant. The latter’s PPE is like he is prepared for takeoff in space. However, the autopsy includes hours physically demanding work that should be comfortable. This re-breather space suit looking equipment is a prescription for errors and trauma. While spending many hours in the morgue doing autopsies, I can state this with some credibility, including my misfortunes.

Face protection by a pathologist and a morgue assistant

The photo also demonstrates misunderstanding of the principle of PPE in an infectious disease case autopsy. While wearing N95 mask, which according to OSHA/CDC guidelines should be used in the case of oscillating saw aerosol production, both on the photo expect the virus emanating from the body or evisceration organs. The virus does not know where their nose or mouth are. If it exists in the air, the virus landing will be proportionally distributed, including the open neck area. Actually, they are wearing a combination of two masks (N95 and surgical mask) that is unbearable for a prolonged work.

Conclusion

These are questions from a person who has experience in autopsy performances, including on decedents from infectious diseases. I haven’t seen, heard, or read about infection inoculation in the autopsy room. Pathologists are burdened by special knowledge that brings some responsibility. It is a shame to hide behind OSHA and CDC limitations for autopsy performances which are determined by unsubstantiated fear of unknown. Actually, it is the College of Anatomic Pathologists professional group’s disservice to the society, a kind of malpractice.

CDC’s Autopsy Guidance for COVID-19

This post is going to analyze some points of June 15, 2020 Interim Guidance for Collection and Submission of Postmortem Specimens from Deceased Persons with Known or Suspected COVID-19. Although the Guidance is intended to bring CDC’ recommendations regarding postmortem examination, it is remarkable also as a reflection of CDC’s position on general COVID-19 issues. This interim guidance is based on what is currently known about corona virus disease 2019 (COVID-19). The official document will be quoted in italics.

Current knowledge supports that spread of SARS-CoV-2 (the virus that causes COVID-19) usually happens when a person is in close contact (i.e., within about 6 feet) via respiratory droplets produced when an infected person coughs, sneezes, or talks. This route of transmission is not a concern when handling human remains or performing postmortem procedures. It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes. This is not thought to be the main way the virus spreads, but we are still learning more about how this virus spreads. CDC will update this interim guidance as additional information becomes available.

At least on June 15, 2020 CDC thinks that in postmortem activities, virus is transmitted via respiratory droplets, although persons in dirty by contaminate surface gloves can also transmit the virus by touching their mouth or eyes, as well as aerosol generation when using in rare occasions an oscillating saw.

“This is not thought to be the main way the virus spreads.” What is the main way?

“…we are still learning more about how this virus spreads.” CDC does not know more about the virus still after being already in epidemic for half a year.

CDC will update this interim guidance as additional information becomes available.” Today, on July 6, 2020, an update is not available for general public.

The limitations imposed by CDC recommendations for PPE and engineering controls in the morgues and mortuary facilities are certain and often difficult to meet (see below the excerpt from the CDC Guidance).

Engineering Control Recommendations for Autopsies

Autopsies on decedents known or suspected to be COVID-19 cases 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 Have air exhausted directly outside or through a high efficiency particulate aerosol (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 also be placed in the room to provide further air filtration. 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. AIIR room air should never be recirculated in the building, but directly exhausted outdoors, away from windows, doors, areas of human traffic or gathering spaces, and from other building air intake systems.

Why should autopsies be conducted in airborne infection isolation rooms (AIIRs)? Where is published the CDC’s explanation for these recommendations? This is the aerosol transmission prevention.

PPE Recommendations for Autopsies

The following PPE should be worn during autopsy procedures:

Double surgical gloves interposed with a layer of cut-proof synthetic mesh gloves Fluid-resistant or impermeable isolation gown Waterproof apron Goggles or face shield NIOSH-approved disposable N-95 or higher respirator Powered, air-purifying respirators (PAPRs) with HEPA filters may provide increased worker comfort during extended autopsy procedures.

The background for policies and autopsy service.

Why are double surgical gloves interposed with a layer of cut-proof synthetic mesh gloves recommended for an autopsy? What kind of virus spread can a N95 or higher respirator prevent?

Maybe, CDC and other health care authorities know something that they do not want or cannot disclose. My conspiracy guesses will be presented in the SARS-CoV-2 virus Aerosol post.

Puzzling are recommendation for the autopsy performance indications. It is unclear why COVID-19 is not a regular infection disease as far as an autopsy is concerned.  At current time COVID-19 has epidemic dissemination according to morbidity and mortality statistics. Although CDC recommendations are the background for OSHA policies, the real damage of ambiguity in CDC recommendations is limitations of autopsy performance for medical and epidemiological practice.

Recommendations about the type of postmortem specimens to collect vary based on whether the case of COVID-19 is suspected or confirmed, as well as whether an autopsy is performed.

The following factors should be considered when determining if an autopsy will be performed for a deceased known or suspected COVID-19 case:

Medicolegal jurisdiction                      Facility environmental controls                  Availability of recommended personal protective equipment (PPE)                  Family and cultural wishes  

Why should medicolegal jurisdiction be considered? Is not an autopsy on the COVID-19 case a regular pathology service rather than medicolegal procedure? 

In a different the Guidance’s place, there is a following passage:

Medical examiners, coroners, and other healthcare professionals should use professional judgment to determine if a decedent had signs and symptoms compatible with COVID-19 during life and whether postmortem testing is necessary. Or The guidance can be used by medical examiners, coroners, pathologists, other workers involved in providing postmortem care, and local and state health departments. Or in a different place in the same third in the line sequence Complete autopsies could be warranted in certain circumstances, as determined by the medical examiner, coroner, or community pathologist.

A pathologist is among other healthcare professionals or third after medical examiners and coroners. What does community pathologist mean? What is behind “criminalization” of an infectious disease? There are other confusing inconsistencies in the Interim Guidance for Collection and Submission of Postmortem Specimens from Deceased Persons with Known or Suspected COVID-19 document, updated  on June 15th 2020, but this post includes only questions to the  CDC’s recommendation  on the autopsies performance regulations and safety issues during the COVID-19 epidemic time.                           

Letters to CAPTODAY

Two articles about autopsies appeared in CAPTODAY’s  May  Suiting up for COVID-19 autopsies, sharing findings” and June Autopsies Show many Faces of COVID-19 issues. The articles are remarkable as a reflection of current state of declining autopsies as teaching tool for medicine. During the COVID-19 epidemic outbreak this tendency became especially visible. OSHA and hospital’s administration with the silent node of College of American Pathologists actually put autopsies on a hold just in time when the epidemic required the opposite.

However, before I am placing a post, which analyzes some points of June 15, 2020 Interim Guidance for Collection and Submission of Postmortem Specimens from Deceased Persons with Known or Suspected COVID-19. This documents sheds some light on the reasons for pathology community confusion regarding autopsy performance during the COVID-19 epidemic.

I responded to both articles with two letters to the Editor. The letters were not published in this College of American Pathologists magazine. Both letters are below. I’m going to make more expanded analysis both letters in a separate post with the concentration on organizational and technical issue rather on medical part for understandable reasons.

The letter on 6/11/20

To the Editor:

The May issue’s “Suiting up for COVID-19 autopsies, sharing findings” article shows that postmortem examinations are returning to their main goal of a teaching tool. Hopefully, College of American Pathologists encourages broader autopsy performance and coordinates the autopsy data collection.

There is no reliable scientific data that COVID-19 is different from other respiratory infections initiated by coronaviruses as far as transmission is concerned. The aerosol component in transmission is still disputed. For understandable reasons, SARS-CoV-2 virus transmission through sneezing or speaking droplet nuclei cannot be taken into account during an autopsy.  The aerosolization is quite preventable by proper autopsy technique and air flow engineering controls.

The use of personal protective equipment (PPE) is obligatory in every autopsy. It is reckless to do an autopsy without double gloves or a face shield, especially during evisceration or bone cutting. The layers of protective equipment mentioned in the article (even a biohazard-type suit) do not assure safety if the rules of donning and especially doffing are not followed. An autopsy requires hours of work. A reflection of unsubstantiated fears, the suggested in the article PPE does not provide conditions for comfortable performance of the multiple tasks during the procedure. The work without comfort is the way to mistakes and trauma. The grossing-technology.com website’s COVID-19 blog discusses in detail protective equipment and autopsy room/table maintenance during the procedure.

Just friendly remarks on the LSU School of Medicine pathology department’s honorable efforts to collect invaluable data in the midst of the COVID-19 epidemic. Unfortunately, this is not the last epidemic that the anatomic pathology will encounter.

Izak B. Dimenstein, MD, PhD, HT (ASCP)    

The letter on 6/24/20

To the Editor:

The article Autopsies show many faces of COVID-19 is evidence that postmortem examinations are returning as a teaching tool for clinicians and the resource for the scientific comprehension of COVID-19 anatomic pathology data. Unfortunately, precious material has been lost by OSHA’s confusing regulations and administrative restrictions, including two autopsies per week limitation. Administrative decisions are often marred by self-preservation, especially in current pandemic of fear. It is hard to believe that OSHA issued the regulatory restrictions without consultation with pathologists. LISTSERV communications and the CAP Autopsy Committee’s involvement are very useful.

Dr. Rapkiewitz is right that that COVID autopsy is not different from an influenza autopsy. There is no reliable scientific data that COVID-19 is different from other infections initiated by coronaviruses as far as transmission during an autopsy is concerned. In contrast to clinical work, for understandable reasons, SARS-CoV-2 virus transmission through sneezing or speaking droplet nuclei cannot be taken into account during an autopsy.  Strict adherence to OSHA standard PPE can provide safe and comfortable work. An autopsy requires hours of work with performance of multiple tasks. The grossing-technology.com website’s COVID-19 blog discusses in detail protective equipment with attention to donning, especially donoff, as well as some additional measures to prevent aerolization potentially infectious material during the procedure.

An autopsy, which is performed under relatively tranquil condition in contrast to the patient’s ward, should use all array of modern laboratory tests, including for Disseminated Intravascular Coagulation (DIC) diagnosis. Also, the reliability of the molecular rRT-PCR test can be checked. The test is assumed as impeccable, as the final verdict.

Izak Dimenstein

                                                                                                                                                                                         

Prevention SARS-CoV-2 virus aerosolization during an autopsy

Introductory words

This post is concentrated only on prevention SARS-CoV-2 virus aerosolization during an autopsy. Proper autopsy technique and air flow engineering controls in the morgue’s room are the subject of discussion.

It would be a shame that anatomic pathology is losing such precious learning material as COVID-19 autopsy data. Stifled by regulators and the fear of unknown, pathologists delayed their autopsies activities in the beginning of the COVID-19 epidemic outbreak. Although now the OSHA’s position has been changed, in the beginning of the epidemic the agency had not recommended autopsies.

There is no any scientifically supported evidence that COVID-19 is different from other respiratory infections initiated by corona viruses as far as transmission is concerned. The main way of transmission is by droplet nuclei containing viruses through mucous excretions from infected person with or without disease symptoms. The decedent does not sneeze, cough, speak, or shed viruses in the environment. Although the aerosol component in transmission is still disputed, this is only one possible way of become an infection source during the autopsy performance.

Assumption of possible virus aerosolization

To be on more or less scientific ground in understanding of the virus aerosolization mechanism, it is necessary to touch some biology and physics basics. We are going to do with maximal simplification.

 A viable SARS-CoV-2 virus cannot exist without its protein-lipid envelop. The virus is dwelling in the mucus which is made up of 95% water, although mucus contains other ingredients such as mucin (2%–3%), proteoglycans, lipids proteins, and DNA. Virus has the binding attachment to specific molecules on the surface of the cells. Molecules in water content follow the kinetic energy random motion when the the fastest can overcome Van der Walls power and escape from the surface in vapor. The speed and intensity of evaporation increases with velocity, temperature and diminished humidity. It means that air circulation even 6 per hour, never mind 12 per hours as CDC suggests, only increases possibility of viruses aerosolization. Horizontal laminate airflow with 6 or 12 per hour circulations has been  developed for diminishing gas (formaldehyde, for instance) and fumes, but in the case of the autopsy procedure such design contributes to aerosol formation just at the zone of the work.

This is my understanding of the infectious aerosol’s development during an autopsy. Moreover, the conditions for aerosol development is more possible than in a patient’s ward during a ventilator handling. During an autopsy, the large surfaces of respiratory tract, including bronchi and lung, digestive tract are open. Under certain conditions, evaporation and aerolization of light droplet nuclei might be possible. Of course, if the virus exists in the body. However, we have to assume that it is just in case.

My practical recommendations

These recommendations are only for the prevention SARS-CoV-2 virus aerosolization during an autopsy procedure. They stem from my understanding of the aerosolization process and hands- on work in the autopsy rooms. Some points might be controversial and require a critical discussion.

Timing of the autopsy

Delay of the autopsy for many reasons is not only unnecessary but contra productive because SARS-CoV-2 virus needs only mucosa epithelial cell for reproduction. The body becomes more inhabitant without immunology mechanisms of living organism’s defense. The viral load might increase during the delay. This is in contrast with HIV which is a blood infection.

Autopsy room preparation

The autopsy room should be prepared by vacuuming. Floors, walls, and tables should be cleaned by water horse spray without using any disinfectant because the goal is to diminish the amount of dust, as potential carriers of aerolized virus, although it will remain anyway but in lesser quantity. This also increases the humidity in the room.

Disinfection would be obligatory after the autopsy procedure. Additional ultraviolet insolation would be advisable.

Autopsy procedure

The body should be washed, especially the upper part (face, shoulders).

Every splash outside the body on the table and the floor during the procedure should be immediately washed off to prevent the evaporation and the virus aerosolization as its result.

Minimal use of oscillating saw that create particles which can be loaded with evaporating/aerosolized infectious material. Brain examination would be reasonable only by special indications. Oscillating saw can be completely excluded by using old fashioned Satterlee saw. This is physically demanding work and require some skill. I had used it under special conditions.                The chest cage can be opened through the cartilages of sternum/ ribs junctions cut using a dissection knife.

Cartilages of sternum /ribs junction cut by a dissection knife

The opened space is wide enough for following manipulations. After some training, it can be done with one movement by the dissection knife. I have always opened the chest cage in this way. CDC’s recommendation for using hand shears (this instrument is called rib shear) as an alternative cutting tool to oscillating saw is not right because some bone particles are generated and they fall down into the thorax cavity. In general, this method is not safe, because the sharp rib’s edges may be responsible for a glove unnoticed tear with many unfortunate consequences during manipulations inside the thorax cage.

Bone Dust Vacuum Collector can by used if an oscillating saw were employed, according to the Mopec’s advertisement. The device is compatible with the Mopec 5000 Autopsy Saw only. I don’t have any comment because I haven’t seen it. It cost is 1,999. 95.

The pathologist should see the organs with no delay after evisceration. The pathologist’s participation during evisceration or selected gross inspection in situ is highly advisable.

The body should be closed as much as possible fast.

Remarks on engineering control in the autopsy room

Lowering the speed (velocity) decreases the intensity of evaporation. It means that air circulation even 6 per hour, never mind 12 per hours, as CDC suggests, only increases possibility of droplet nuclei evaporation, i.e.  viruses aerosolization. Horizontal laminate airflow with 6 or 12 per hour circulations has been developed for diminishing gas (formaldehyde, for instance) and fumes, but such design contributes to aerosol formation just at the zone of the work in the case of the autopsy procedure. This kind of ventilation is counterproductive during evisceration and when potentially containing viruses’ surfaces are open. Intensive air circulation (6-12 per hour) is reasonable when the dissection is over and the body is closed.

Lowering the room temperature and increasing humidity decreases evaporation. Those are additional room environment conditions for the virus aerosolization prevention.

Personal Protective Equipment

Personal Protective Equipment (PPE), which is recommended by CDC and OSHA, takes into account possibility of SARS-CoV-2 virus aerolization during autopsy. Details of PPE (masks, eye protection, gowns, gloves, etc.) are discussed on grossing-technology.com website Blog’s category COVID-19 Protective equipment. PPE issue is out of the current article’s scope which is concentrating only on the aerosolization during the autopsy.