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.                           

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