Covid-19 seems to be here to stay. While we keep physical distance from each other to ensure the living do not infect other living, it is also important to know that to do so the dead too do not kill the living. This presentation gives an overview of certification of death in the ear of covid-19 and standards for autopsy practice for a Grade 3 biohazard such as the SARS- Cov 2

1. DEATH CERTIFICATION AND
MINIMUM STANDARDS FOR
AUTOPSY IN THE ERA OF COVID-19
Dr. Onoro E.B
21ST May, 2020.

2. OUTLINE
 Introduction
 Background
 Definition of death due to Covid-19
 Guidelines for certification
 Guidelines for autopsy in Covid-19 deaths
 Safety guidelines for performing such autopsies
 Conclusion
 References

3. INTRODUCTION
 In December 2019 a novel Coronavirus (SARS-
CoV-2) was identified as the causative agent of a
severe acute respiratory illness (COVID-19) in
Wuhan, China. The virus spread to different
countries and WHO declared a pandemic on March
11, 2020.
 There are still some uncertainties in the natural
history of the COVID-19, including source(s),
transmissibility mechanisms, viral shedding, and
persistency of the virus in the environment.

4. INTRO CONT’D
 Human-to-human transmission has been
documented, with incubation period from 2 to 14
days.
 Transmission of infectious diseases associated with
management of dead body can occur and can be
enhanced by non-compliance to standard and
transmission-based precautions, especially in
healthcare settings.

5. BACKGROUND
 In the majority of clinical deaths from Covid-19,
respiratory failure is the proximate cause of death.
 However, autopsy findings in a recent study
showed that, in the presence of other comorbidities,
patients may die with the disease rather than from
it.

6. BACKGROUND CONT’D
 This presents a dilemma of sorts when it comes to
deciding what the cause of death on the death
certificate should be.
 Transmission of infectious diseases associated with
management of dead body can occur and can be
enhanced by non-compliance to standard and
transmission-based precautions, especially in
healthcare settings.

7. BACKGROUND CONT’D
 Aerosol generating procedures (AGPs) have a role
in the spread of the disease, as well as
contaminated hands of healthcare providers,
surfaces and fomites.
 SARS-Cov-2 is one of the organisms in the Hazard
Group 3, and for such autopsies, it is required that
certain minimum criteria be fulfilled.

8. DEFINITION
 A death due to COVID-19 is defined for surveillance
purposes as a death resulting from a clinically
compatible illness, in a probable or confirmed
COVID-19 case, unless there is a clear alternative
cause of death that cannot be related to COVID
disease (e.g. trauma). There should be no period of
complete recovery from COVID-19 between illness
and death.

9. DEFINITION CONT’D
 A death due to COVID-19 may not be attributed to
another disease (e.g. cancer) and should be
counted independently of preexisting conditions
that are suspected of triggering a severe course of
COVID-19.

10. GUIDELINES FOR CERTIFICATION
 In view of COVID-19 it is important to record and
report deaths due to COVID-19 in a uniform way.
 Recording COVID-19 on the MCCD
 Terminology
 Chain of events
 Comorbidities

11. Recording COVID-19 on the MCCD
 COVID-19 should be recorded on the medical
certificate of cause of death for ALL decedents
where the disease caused, or is assumed to have
caused, or contributed to death.

12. Terminology
 The use of official terminology, COVID-19, should
be used for all certification of this cause of death.
 As there are many types of coronaviruses, it is
recommended not to use “coronavirus” in place of
COVID-19.

13. CHAIN OF EVENTS
 Specification of the causal sequence leading to
death in Part 1 of the certificate is important.
 For example, in cases when COVID-19 causes
pneumonia and fatal respiratory distress, both
pneumonia and respiratory distress should be
included, along with COVID-19, in Part 1.
 Certifiers should include as much detail as possible
based on their knowledge of the case, as from
medical records, or about laboratory testing.

14. CHAIN OF EVENTS

15. COMORBIDITIES
 There is increasing evidence that people with
existing chronic conditions or compromised immune
systems due to disability are at higher risk of death
due to COVID-19.
 Chronic conditions may be non-communicable
diseases such as coronary artery disease, chronic
obstructive pulmonary disease (COPD), and
diabetes or disabilities.

16. COMORBIDITIES
 If the decedent had existing chronic conditions,
such as these, they should be reported in Part 2 of
the medical certificate of cause of death.

17. COMORBIDITIES

18. GUIDELINES FOR AUTOPSY IN
COVID-19 DEATHS
 In general, if a death is believed to be due to
confirmed COVID-19 infection there is unlikely to be
any need for an autopsy.
 On the other hand, if a death is suspected to have
been due to Covid-19 but the infection was not
confirmed at the time of death, assessment will be
based on the same set of criteria used in assessing
risk in the living, viz:

19. GUIDELINES CONT’D
Inpatient definition
 requiring admission to hospital
 and
 have either clinical or radiological evidence of
pneumonia
 or
 acute respiratory distress syndrome
 or
 influenza like illness (fever ≥37.8°C and at least one of
the following respiratory symptoms, which must be of
acute onset: persistent cough (with or without sputum),
hoarseness, nasal discharge or congestion, shortness
of breath, sore throat, wheezing, sneezing

20. GUIDELINES CONT’D
 Out-patient
 new continuous cough and/or
 high temperature

21. GUIDELINES CONT’D
 If by using these criteria it is felt that a death may
be due to COVID-19, the decisions to be taken are:
 Whether to proceed to post-mortem examination or not.
 The extent of the autopsy
 Is the examination limited to obtaining the necessary
swabs and samples to confirm COVID-19 infection
 Should it entail a fuller more invasive post-mortem
examination?

22. GUIDELINES CONT’D
 It is recommended that autopsies on likely Covid-19
bodies should be staged by first taking samples to
assess for COVID-19 infection.
 Only after these results have been assessed should
a fuller, more invasive post-mortem examination be
carried out.
 Autopsies after confirmation of infection are mainly
for academic or research purposes.

23. SAFETY GUIDELINES FOR
COVID-19 AUTOPSIES
 CRITERIA
 the mortuary is sufficiently well-equipped, safe and
accredited
 the anatomic pathology technologists are comfortable
with continuing the examination
 the pathologist has knowledge of what they might
encounter in the organs and how to proceed with
sample selection and then interpretation of the
histopathology.

24. SAFETY GUIDELINES CONT’D
 If these conditions are not fulfilled, then either a
more experienced pathologist may be invited to
perform the autopsy in the same mortuary, or the
case may be referred to another mortuary that is
appropriately equipped and staffed.

25. SAFETY GUIDELINES CONT’D
 CLINICAL INFORMATION
 In addition to standard clinical information and
location of death, knowledge of past international
travel, laboratory data and microbiology data
(positive and negative) are critical.
 It is important not to assume that the information
provided is accurate.

26. UNIVERSAL PRECAUTIONS
 Aerosol-generating procedures such as use of an
oscillating bone saw should be avoided for known
or suspected COVID-19 cases. Consider using
hand shears as an 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.
 Limit the number of personnel working on the
human body at any given time.

27. UNIVERSAL PRECAUTIONS
 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.

28. PPE
 All employers have to protect the health and safety
of their employees under the Health and Safety at
Work Act 1974.
 PPE is essential. It is standard for all autopsies that
pathologists and APTs wear the following:
 surgical scrub suit
 hat to protect hair
 clear visor to protect the face, eyes and mouth
 respiratory protection, either as a standard surgical
mask or a FFP3 mask, which more effectively excludes
small particles of infective material

29. PPE CONT’D
 a waterproof gown that covers the entire body, including
the forearms
 a plastic apron over a waterproof gown
 rubber boots with metal-protected toecaps and dorsal
reinforcement
 under single use disposable non-latex gloves, protective
gloves made of kevlar or neoprene, which are cut-
resistant in case of potential blood-borne infection.

31. ENGINEERING AND ENVIRONMENTAL
CONTROLS
 Autopsies on known or suspected 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, and
have air exhausted directly outside or through a
HEPA filter.
 Doors to the room should be kept closed except
during entry and egress.

33. ENGINEERING AND ENVIRONMENTAL
CONTROLS
 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.

34. ENGINEERING AND ENVIRONMENTAL
CONTROLS
 Local airflow control (ie, 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.

35. ENGINEERING AND ENVIRONMENTAL
CONTROLS
 Engage a minimum number of staff in the
procedure, and perform only if:
 an adequately ventilated room suitable for the
procedure is available.
 appropriate PPE is available; scrub suit, surgical mask
or if AGP particulate respirator or N95 mask, long
sleeved fluid-resistant gown, gloves (either two pairs or
one pair autopsy gloves) and face shield (preferably) or
goggles, boots.

36. ENGINEERING CONT’D
 For reduction of aerosol generating procedures
during such autopsies, these should be considered:
 use containment devices (e.g. biosafety cabinets for the
handling and examination of smaller specimens).
 use vacuum shrouds for oscillating saws.
 do not use high-pressure water sprays.
 if opening intestines, do it under water.

37. TABLE 1 – USE OF PERSONAL PROTECTIVE EQUIPMENT
ACCORDING TO THE PROCEDURE RELATED TO THE MORTUARY
MANAGEMENT OF COVID-19.

38. TABLE 2 – TECHNICAL SPECIFICATIONS FOR PERSONAL PROTECTIVE
EQUIPMENT FOR PROCEDURES RELATED TO THE MORTUARY
MANAGEMENT OF COVID-19.
Safety measure Details
Hand hygiene alcohol based hand rub
running water
liquid plain soap for hand hygiene
disposable towel for hand drying
(paper or tissue)
PPE gloves
waterproof plastic apron
long sleeve gowns
anti-fog googles
face shield
N95 respirator or surgical mask
Waste management and
environmental cleaning
disposal bag for bio-hazardous
waste
Soap and water or detergent
disinfectant for surfaces –
hypochlorite solution 0.1% (1000

39. LIMITED AUTOPSIES
 There has been much research on the utility of
limited autopsies (i.e. needle sampling or single
opening organ sampling) in the context of autopsy
practice in resource-poor countries with limited
mortuary facilities and staff.
 Such minimally invasive autopsies (MIA) are
undoubtedly useful in cases of systemic infection by
viruses and bacteria, where sampling blood, liver
and spleen will reliably provide diagnostic samples
and provide an anatomic cause of death.

40. CONCLUSION
 Covid-19 is an acceptable direct or underlying
cause of death for the purposes of completing the
death certificate.
 That Covid-19 is a notifiable disease does not
mean referral to a coroner is required by virtue of
this status.
 Every autopsy carries the potential risk of
transmission of infection and even more so when it
involves a confirmed or suspected case of Covid-
19.
 Safety precautions by way of both PPEs and
appropriate environmental engineering need to be
ion place to mitigate the risks.

41. REFERENCES
1. International guidelines for certification and Classification
(coding) of covid-19 as cause of Death based on
International statistical classification of diseases (16 april
2020)
2. Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A
familial cluster of pneumonia associated with the 2019 novel
coronavirus indicating person-to-person transmission: a
study of a family cluster. Lancet. 2020.
3. The epidemiological characteristics of an outbreak of 2019
novel coronavirus diseases (COVID-19) in China].
Zhonghua Liu Xing Bing Xue Za Zhi. 2020;41(2):145-51.
4. World Health Organization. WHO Director-General's
opening remarks at the media briefing on COVID-19 - 11
March 2020 Geneva2020
5. Coronavirus Disease 2019 (COVID-19) Autopsy Guidance
FAQ https://emedicine.medscape.com/article/2500121-
overview?src=mkm_200514_mscpmrk_COVID_feature_Aut
opsy&uac=349717PT&impID=2380938&faf=1