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Guide to Forensic Pathology Practice for Death Cases Related to Coronavirus Disease 2019 (COVID-19) (Trial Draft)‡

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Guide to Forensic Pathology Practice for Death Cases Related to Coronavirus Disease 2019 (COVID-19) (Trial Draft)‡ FORENSIC SCIENCES RESEARCH 2020, VOL. 5, NO. 1, 1–7 https://doi.org/10.1080/20961790.2020.1744400 GUIDELINE Guide to forensic pathology practice for death cases related to coronavirus disease 2019 (COVID-19) (Trial draft)‡ aà aà a a a a b Danmi Mao , Nan Zhou , Da Zheng , Jiacheng Yue , Qianhao Zhao , Bin Luo , Dawei Guan , Yiwu Zhouc, Bingjie Hud and Jianding Chenga# aFaculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China; bSchool of Forensic Medicine, China Medical University, Shenyang, China; cDepartment of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; dDepartment of Pathology, Guangzhou Medical University, Guangzhou, China ABSTRACT ARTICLE HISTORY Autopsy is of great significance for elucidating the pathological changes, pathogenesis and Received 16 March 2020 cause of death of Coronavirus Disease 2019 (COVID-19) and can provide a theoretical basis Accepted 16 March 2020 for scientific and accurate prevention and control of its outbreak. Based on related laws and KEYWORDS regulations, such as the Law of the People’s Republic of China on Prevention and Control of Forensic sciences; forensic Infectious Diseases, clinical manifestations and epidemiological characteristics of COVID-19 and pathology; autopsy; SARS- guidelines on the prevention and control of this epidemic, combined with the practical work CoV-2; Coronavirus Disease of forensic pathology examinations, we developed the Guide to Forensic Pathology Practice for 2019 (COVID-19); guide Death Cases Related to Coronavirus Disease 2019 (COVID-19)(Trial Draft). This guide describes the background investigation of the death cases, autopsy room requirements, personal pre- vention and protections, external examinations, autopsy practices and auxiliary examinations, and thus offers a reference for forensic and pathological examination institutions and staff. Introduction and the survival time of the viruses may be prolonged in refrigerated cadavers. During epidemic prevention Since December 2019, an outbreak of infection with and control, forensic pathologists may examine the the novel coronavirus (SARS-CoV-2) in China has pro- body and tissues of the deceased infected with SARS- gressed to many countries worldwide, raising concerns CoV-2 (including asymptomatic or suspicious infec- regarding Coronavirus Disease 2019 (COVID-19) tion). According to the Law of the People’sRepublicof endangering public health and life [1]. On 20 January China on Prevention and Control of Infectious Diseases 2020, COVID-19 was listed as a Category B infectious [5], Regulations on biosafety management of patho- ’ disease according to the Law of the People s Republic genic microorganism laboratories [6], Regulations on of China on Prevention and Control of Infectious autopsyofpatientswithinfectiousdiseasesorsuspected Diseases by the General Office of the National Health infectious diseases [7], Notice of guidelines for disposal ’ Commission of the People s Republic of China, while of the remains of patients with pneumonia infected by the related prevention and control measures follow novel coronavirus (trial version) [8]andDiagnosis and the standards of Category A infectious disease. On 30 treatment of novel coronavirus pneumonia (trial ver- January 2020, the World Health Organization sion sixth) [2], the guidelines in this article provide declared the outbreak of COVID-19 a Public Health recommendations for biosafety and infection control Emergency of International Concern. practices during specimen collection and handling, as With high infectivity, the incubation period of well as autopsy procedures. COVID-19 is approximately 14 days, and lasts for 24 days or more, in some patients [1–3]. One report General rules for forensic pathology [4] showed possible transmission between asymp- examination tomatic patients or between patients during the incubation period. A large amount of viruses may 1. Forensic institutions should follow the regulations remain in deceased people infected with SARS-CoV-2, of their national and local health departments CONTACT à Yiwu Zhou [email protected]; Bingjie Hu [email protected]; Jianding Cheng [email protected] These authors contribute equally to this work #Translated by Jianding Cheng ‡This guideline was first published in Fa Yi Xue Za Zhi, February 2020;36:1. doi:https://doi.org/10.12116/j.issn.1004-5619.2020.01.003. This is a transla- tion by Jianding Cheng from the original work entitled 新型冠状病毒感染相关死亡的法医病理学检验建议指南（试行稿） by Mao DM, Zhou N, Zheng D, et al., published by permission of Fa Yi Xue Za Zhi. ß Jianding Cheng 2020. All Rights Reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 D. MAO ET AL. when formulating work procedures and emergency chain reaction testing or (2) a high homology to plans for epidemic prevention and control. SARS-CoV-2, as indicated by viral gene sequencing. 2. To effectively confirm a SARS-CoV-2 infection or a suspected case, investigating the death pro- Latent cases cess and medical history, and a case review are Asymptomatic infection and patients in the incuba- the first and most pivotal work in forensic aut- tion period may become sources of infection; there- opsy regarding epidemic prevention. fore, identifying latent cases is the most critical task 3. Knowledge of COVID-19 should be updated for forensic pathologists. timely, and the recommended practices and People who do not meet the diagnostic criteria principles should be followed to avoid infection. for suspected cases, but possess any of the following Autopsy sites should have safety and protection features, are recommended to undergo screening as protocols in place to guarantee personal and possible latent cases: (1) meet some of the items “ ” public safety. listed for suspected COVID-19 but have not reach the diagnostic thresholds for suspected cases yet; (2) have the following epidemiological history: travel Contents of the forensic pathology history or residence history in Wuhan or surround- examination ing cities or communities reporting confirmed cases, Case investigation close contacts of persons with COVID-19 (with positive nucleic acid test results) and/or exposure Investigation involves collecting the deceased’s med- history to patients coming from Wuhan or sur- ical history and death process information obtained rounding cities or communities with confirmed from clients (court or police), hospitals, family cases; (3) have the following clinical features: fever members, witnesses, funeral establishments, initial and/or respiratory symptoms, abnormal peripheral examiners and others. If necessary, clinicians are blood WBC count (with normal or reduced total consulted to determine whether the deceased was a WBC count or reduced lymphocyte count); and (4) confirmed infection or a suspected case [2,9]. imaging characteristics of SARS-CoV-2 infection. Suspected cases [2] Epidemiological history. Fourteen days prior to Categorising protection strategies symptom onset: (1) travel history or residence history Before performing a postmortem examination, in Wuhan or surrounding cities or communities forensic examiners should consider the above crite- reporting confirmed case(s); (2) close contacts of per- ria and determine whether a case is related to sons with COVID-19 (with positive results after COVID-19, and if yes, determine the category for nucleic acid testing); (3) exposure history to patients the case: suspected, confirmed or latent. After cat- with fever or respiratory symptoms who came from egorisation, protection and testing are performed Wuhan, surrounding cities or communities with con- according to the following principles: firmed case(s) and (4) evidence of clustering. Confirmed and suspected cases. Biosafety level 3 Clinical features. (1) fever and/or respiratory symp- (BSL-3) protection should be provided during the toms; (2) in early onset, the total number of white scene investigation. The body, with clothes carefully blood cells (WBC) was normal or decreased, or the removed, is gently moved to avoid blood and/or lymphocyte count was decreased; and (3) imaging excrement contamination. Disinfectant containing characteristicsofCOVID-19assmallpatchyshadows 1 000 mg/L of chlorine should be used for on-site and interstitial changes appeared early, especially in disinfection. Cadaver examination should be per- the lateral lung. Ground-glass opacities and infiltrates formed in the autopsy room with BSL-3 protection. were seen subsequently in bilateral lungs. Lung con- The autopsy personnel’s clothing should meet the solidation might occur in severe cases. BSL-3 protection standards, strengthening the anti- A suspected COVID-19 patient must have one of splash protection for the face [6,10,11]. the epidemiological history features and meet any two of the clinical features, or meet three clinical Latent cases. The site should be ventilated for at features and none of the epidemiological features. least 10 min before the crime scene investigation. Examiners should, with clothing following BSL-3 or Confirmed cases BSL-2 protection standards, stand on the windward A confirmed case must have one of the following side and maintain a distance from the mouth and two etiological evidences [2]: (1) nucleic acid-posi- nose of the
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