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Forensic Medicine Practice in the Time of COVID-19 Pandemic: Challenges and Future Perspectives Shereen A Elkhateeb1, Marwa A. Amer1 Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Zagazig University, Egypt1

Corresponding author: ABSTRACT In the last few months, COVID-19 pandemic caused some challenges for Shereen Ahmed Elkhateeb forensic practitioners. The crimes are still being committed and people still [email protected] die due to causes not related to COVID-19, where the forensic practitioners is asked to clinically examine some cases and identify the cause and manner of death for others. Consequently, the forensic physicians will continue to examine victims of violence and the forensic pathologists should keep doing the autopsy of the corps of those killed by murder , suicide, accidentally or even sudden and unexpected death (like cases of heart attack or stroke). As any other individual in the community, these medico-legal cases may also be infected with COVID-19. SO, all forensic practitioners are at risk to catch COVID-19 infection either during examination of clinical cases that may be infected or during autopsy of infected bodies. The purpose of this review article is to know the potential risks facing forensic practitioners during examination of cases or doing autopsy in COVID-19 pandemic. It also indicates how to manage the dead bodies of suspected or confirmed cases of COVID-19 virus infection in order to minimize the risk of environmental contamination and the contagion of forensic practitioners and the proper guidelines and recommendations for the future. Key wards: Forensic practitioners; clinical examination; death investigation; COVID-19 pandemic.

. 1. INTRODUCTION the refrigerated corpses may be increased (Mao, et al., 2020). disease 2019 (COVID-19), COVID-19 outbreak has created certain is a worldwide health issue (WHO, 2020). The challenges for forensic workers. Autopsy in the most recently discovered coronavirus SARS- time of COVID-19 outbreak is considered a CoV-2 is considered belonging to hazard group high risk autopsy. Risk of infection from 3 (HG3) category of infectious pathogens. HG3 corpses coming for autopsy for any purpose is is a significant group to deal with in clinical unknown and hidden. These bodies may have forensic medical practice and in forensic no past medical records, or if present, contain pathology practice (Osborn et al., 2020). inadequate information. Also, the cases may be COVID-19 virus is highly infective. The asymptomatic. Beside, some of these deaths incubation period is about two weeks, and may have occurred in the hospital and there is a continues for more than three weeks, in some possibility of hospital acquired infections cases (Backer et al., 2020; Liu et al., 2020). A (Sapino et al., 2020). So, the objectives of this significant number of viruses that reside in review article is to know the potential risks deceased persons infected with SARS-CoV-2, facing forensic practitioners during clinical and the survival period of these viruses within

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examination of cases, during autopsy that may surrounding environment around the infected be either pathological, medico-legal or even individual, transmission of droplets may occur via academic and during sample collection in fomites. So, transmission of the SARS-CoV- 2 COVID-19 pandemic. Moreover, the safety may occur through direct contact with infected precautions taken for protection during medical persons and indirect contact with surfaces in the examination of cases, protection of the forensic surrounding environment or with items used during staff in close proximity to dead bodies from infected person 's examination . contracting this infectious disease which may be accidently present and how virtual autopsy can 2. Risks during investigation of the help in this unprecedented time. crime scene Crime scenes should be processed II. THE POTENTIAL RISKS OF rapidly; crime scene investigators may not FORENSIC PRACTICE IN COVID-19 recognize the deceased health status, whether he PANDEMIC TIME (she) was travelled into pandemic area or contacting persons that may be infected. These Forensic practitioners may examine suspicions indicate that the crime scene patients, deceased bodies and tissues infected investigators are facing high risk of catching with SARS-CoV- 2 ((along with non- infection either during scene examination or symptomatic and suspect infections) (Mao et sample collection from scene (Xue et al., 2020). al., 2020). 3. Potential risks during autopsy 1. Potential risks during clinical forensic medical examination of cases COVID-19 virus can survive in an infected deceased body for a period of time after The possibility to catch infection like death, as it has strong survival and can resist COVID-19 during examination of individuals cold environments. The corps of subjects who like prisoners, suspects and victims of crimes in have died of COVID-19 could have huge clinical forensic medical practice may be amounts of the virus. Keeping cadavers in present in this pandemic. Yu et al. (2020) refrigerators can lengthen the virus' persistence displayed possible transmission among non- within the body. In autopsy, forensic symptomatic cases or among cases in the practitioners must do many procedures, where incubation period. Therefore forensic the virus can be passively released and the practitioners have to increase protection possibility of inhaling the virus is increased. In awareness at this critical time. Infection may be addition, sharp instrument injury and contact from patient to doctor or even from doctor to with body fluid spray can raise the risk of patient. exposure during work (Mahallawi., 2018; According to WHO scientific brief in Kampf, 2020; Joseph et al., 2020; Xue et al., March (2020), SARS-CoV- 2 is transmitted 2020). among people through respiratory droplets and touch routes. Transmission of droplets occurs when 4. Potential risks during samples a person has respiratory symptoms (e.g., cough or collection, storage and transfer sneeze) is in close contact with someone (within 1 m) that make this person at risk of exposure the Forensic pathology investigation of certain mucosa of mouth, or conjunctiva to organs need sample extraction, fixation, and potentially infectious respiratory droplets. In the sectioning after autopsy. Samples are then

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Forensic Medicine Practice in …. -3- transferred to the pathology laboratory and negative, autopsy is needed to understand which stored in formalin for more than one week; any natural disease was the cause of the decedent's aerosols have the risk of effusion in air with symptoms. subsequent endangering of physicians (Xue et al., 2020). Forensic practitioners should weight the risks and benefits related to any autopsy request. III. BIOSAFETY RULES Autopsies and any post-mortem diagnostic In the time of COVID-19 pandemic, each maneuver should be carried out in special rooms person or corpse is considered as potential that maintain proper safety conditions and source of infection because of the increasing forensic practitioners should wear protective level of contagion in communities as in overall, N95 mask, face shield and a double pair hospitals and between the general population of autopsy gloves with cut-resistant glove in including asymptomatic cases. So, medico-legal between. Any maneuver which may result in examination of cases or autopsies should be aerosols should be avoided. Organs and tissues accomplished with performing severe biosafety samples for histopathological evaluations must measures (Sapino et al., 2020). be fixed immediately (Sapino et al., 2020). Xue et al. (2020) demonstrated that, autopsies in the Prior to any medico-legal examination of time of pandemic should be performed in a victims, crime scene investigation or deceased superior designed autopsy rooms with three body dissection, forensic practitioners should regions and two buffer sectors (clean region, perform full investigation to determine whether first-level buffer sector, semi-contaminated or not the person or the cause of death has a region, second level buffer sector and connection with COVID-19, in order to take contaminated region). Forensic practitioners suitable protection measurements such as have to dress the personal protective equipment wearing personal protective equipment, in the clean region then consolidate autopsy disinfection of instruments or using special instruments in the semi-contaminated region designed autopsy rooms. Information from before ingoing the contaminated region for victims or relevant to deceased about "flu-like" autopsy. Once finishing the dissection, the symptoms, medical history, history of travel to personal protective clothes should be disinfected an outbreak area or the history of contact with first in the contaminated region then strongly any potentially infected persons. Also, medical disinfecting in the semi-contaminated region a records should be requested from the hospital, second time prior to remove them. Everything family members, eyewitnesses, and mortuary must be directed for bio-safety clearance workers (Xue et al., 2020). immediately. The contaminated region must contain a sufficient suction pressure, filtering It is recommended that, in cases of settings for air release and sewage exoneration autopsies without apparent COVID-19 infection (Mao et al., 2020). Also, the samples sent for to do upper swabs on corpses if histopathological evaluations should be sealed available. It is better to perform the swab within well after sample extraction. The pathology 2 hours of death to assess the absence or laboratory should maintain standard negative presence of COVID-19 infection to apply the pressure operating environments. safety rules (Fineschi et al., 2020). In cases of sudden unexpected death, if the upper IV. VIRTUAL AUTOPSY AS A respiratory tract swab is positive with previous SUBSTITUTION TO ORDINARY history of flue like symptoms, the death may be AUTOPSY IN COVID-19 PANDEMIC certified without an autopsy. But if the test is

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In case of infectious diseases, travel history in an outbreak place or the based on scanning and imaging technology will contact history with any probably infected be a useful safe alternative to conventional people. Measuring the person body autopsy. Performing computed tomography temperature and if available rapid antibody test (CT) scan of the corpse prior to autopsy will may be done before examination. help the forensic pathologists to expect the  Forensic practitioner like any health care cause of death so, prevents them from directly worker should take oral chemoprophylaxis and contacting an infected or asymptomatic corpse. wear personal protective equipment. It is important to do a preliminary judgment on  Regular periodic follow up of forensic the deceased persons whether infected or not to practitioners. take appropriate safety measures during  Procedures for monitoring, managing and subsequent autopsy such as doing upper informing all relative visitors to hospitals, respiratory tract swaps for suspected cases (Xue morgue and prisons. et al., 2020).  Conducting training courses for forensic practitioners on examination of cases, death Combined CT and CT-angiography are investigations and occupational protection considered as sensitive tools in diagnosing awareness for infectious diseases. cause of death. Many studies investigated the sensitivity of postmortem imaging as  Encouraging forensic pathologists to dissect postmortem CT (PMCT), PMCT angiography infected cases especially with different criteria (PMCTA) and postmortem magnetic because, pathological autopsy results in each resonance imaging (PMMR) compared with case will help clinicians to know more about ordinary autopsy in natural and traumatic the disease and understand its mechanisms death cases (Britt et al., 2016; Ampanozi et well. These information will help physicians al., 2020). PMCTA is higher to autopsy plus to put effective treatment protocols so, CT without angiography in detecting medico- decrease morbidity and mortality rats. legally essential findings. The addition of the  Autopsy rooms should be designed with high PMCTA increased the sensitivity of new major biosafety measures and it has to be provided diagnoses from 71.4 % in multiple detector CT with personal protective equipment to allow (MDCT) only to 92.9 % (Wichmann et safe dealing with infected or suspected al., 2012). deceased persons. Special needs as certain suction system to prevent the reflux of V. RECOMMENDATIONS AND FUTURE contaminated aerosols and strong disinfection PERSPECTIVES IN FORENSIC system. Beside, proper ventilation, good water PRACTICE FOR SUCH PANDEMICS: supply, and sewage disposal.  Virtopsy is considered a useful alternative to  Upper respiratory tract swabs traditional autopsy in pandemics, as one of its (nasopharyngeal swab or oropharyngeal swab) advantages is to examine the corpse inside its from suspected autopsy cases. bag and also, allow multiple experts from  In clinical forensic medical practice, thorough different countries to see the examination and investigation of prisoners, suspects and victims share information in the same time through of crimes, prior to examination is useful to tele-forensics. So, forensic practitioners should determine whether or not the person has a increase their experience through continuous relation with COVID-19. This is important to training courses on medico-legal radiology take suitable protective measures. Relevant techniques and should be provided with facts from the person about medical history,

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equipment for virtopsy and high trained 697. https:// doi.org/10.1016/s0140- personnel in multiple morgues. 6736(20)30260-9. 6. Kampf, G., Todt, D., Pfaender, S, et VI. REFERENCES al. (2020): Persistence of 1. Ampanozi, G., Halbheer, D., Ebert, on inanimate surfaces and their L.C. et al. (2020): Postmortem imaging inactivation with biocidal agents. J. J findings and cause of death Hosp Infect. 104; 246-25. determination compared with autopsy: a https://doi.org/10.1016/j.jhin.2020.01.02 systematic review of diagnostic test 2. accuracy and meta-analysis. Int J Legal 7. Liu, Z., Xing Bing, X. and Zhi, X. Med; 134: 321–33. (2020): Expert Group on Novel https://doi.org/10.1007/s00414-019- Coronavirus Prevention and 02140-y. Control of China Preventive Medicine 2. Backer, J.A., Klinkenberg, D. and Association. [An update on the Wallinga, J. (2020): Incubation period epidemiological characteristics of novel of 2019 novel coronavirus (2019-nCoV) coronavirus pneumonia (COVID-19)]. infections among travellers from Wuhan, Chinese;41:139–144. China, 20–28 January 2020. Euro 8. Mahallawi, W.H. (2018): Case report: Surveill. 2020. https:// detection of the Middle East respiratory doi.org/10.2807/1560- syndrome corona virus (MERS-CoV) in 7917.ES.2020.25.5.2000062. nasal secretions of a dead human. J. J 3. Britt, M., Blokker, Ivo M., Taibah Univ Med Sci; 13: 302-304. Wagensveld, Annick C., Weustink, J., https://doi.org/10.1016/ Wolter Oosterhuis, M. G., Myriam j.jtumed.2017.07.004. Hunink (2016): Eur Radiol.; 26: 1159– 9. Mao, D.M., Zhou, N. and Zheng, D. 1179. doi: 10.1007/s00330-015-3908-8. (2020): Guide to the forensic pathology practice on death cases related to corona 4. Fineschi, V. et al. (2020): Management virus disease 2019 (COVID-19) (trial of the corpse with suspect, probable or draft). Fa Yi Xue Za Zhi; 36:6-15. confirmed COVID-19 respiratory https://doi.org/10.12116/j.issn.1004- infection – Italian interim 5619.2020.01.003. recommendations for personnel potentially exposed to material from 10. Osborn, M., Lucas, S., Stewart, R., corpses, including body fluids, in Swift, B. and Youd, E. (2020): morgue structures and during autopsy Briefing on COVID-19 Autopsy practice. Pathologica. practice relating to possible cases of https://doi.org/10.32074/ 1591-951X-13- COVID-19 (2019-nCov, novel 20. coronavirus from China 2019/2020). The Royal Collage of Pathologists. February 5. Joseph, T.W., Kathy, L. and Gabriel, 2020 (online) last seen 12-6-2020. M.L. (2020): Now casting and 11. Sapino, A., Facchetti, F., Bonoldi E., forecasting the potential domestic and Gianatti, A. and Barbareschi, M. international spread of the 2019-nCoV (2020): The autopsy debate during the outbreak originating in Wuhan, China: a COVID-19 emergency: the Italian modelling study. J. Lancet; 395: 689- experience on behalf of Società Italiana

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هوارست الطب الشرعي في وقج جائحت كوفيد-91 : التحدياث وآفاق الوستقبل

شيرين أحود الخطيب1 , هروة عبدالونعن عاهر1 قسن الطب الشرعي و السووم إالكلينيكيت, كليت الطب البشرى, جاهعت السقازيق, هصر1 فٕ األشُر انقهٗهت انهاظٗت ، تسبب ِابا فٗبرِ كّفٗب -91 انهسبجد فبٓ اضبط انجيب ٖاث نهها ابٕ ان ب انشرعٕ. إو اندرائم ال تزال ترتك ، ِ الٖزال انًبا ٖهّتبّو نبى يشبٗا ال ع لبت نُبا تها انبا ادائيبت كّفٗب - 91، ِنى ظبهى انجفبّٖط انقبايّيٕ نهها ابٕ ان ب انشبرعٕ، إجبرا تيقٗب إكهًٗٗكبٓ فبٕ اضبط انيباالث ِتي ٖ اب ِغرٖقت ِفاة ا٘خرٖى. نذا ، اٗسبجهر األغببا انشبرعّٗو فبٕ فيبي ظبياٖا انضًبص ِاّٗا بم يخصببائّٗ ان بب انشببرعٕ تشببرٖم اندلبب نببى يِنتبب انببذٖى ٖهّتببّو اسببب انقجببم يِ االيجيببا يِ انيببّا يِ انهّث انهفاجئ ِغٗر انهجّلع )نلم يّات لهبٗت يِ اكجت ناغٗت(. ِ نلم ئ فبر خخبر فبٕ انهدجهبع ، لب تكبّو َببذٌ انيبباالث ان بٗببت انقايّيٗببت نصبباات يٖ اعببا افٗببرِ انببـكّ ِيا نببذا ، فببئو جهٗببع نها اببٕ ان بب انشببرعٕ نضرظّو نخ ر اإل اات اض ِْ كّفٗ -91 إنا يثًا فيي انياالث انجٕ ل تكبّو نصباات ، يِ يثًبا تشبرٖم اندل انهصاات يِ نى انزِا . انغرض نى َذٌ انهراجضت َّ نضرفت انهخاغر انهيجههبت انجبٕ تّاجبٍ نها ابٕ ان انشرعٕ يثًا فيي انياالث يِ إجرا تشرٖم فٓ ظم جائيت كّفٗ -91. كها ٖشبٗر إنبٓ كٗفٗبت انجضانبم نع اندل نى انياالث انهشجبٍ فُٗا يِ انهؤك ة نض ِْ فٗرِ كّفٗ -91 نى يجم تقهٗم نخاغر انجهّ انبٗتٕ ِع ِْ نها إ ان انشرعٕ ِانقّاع اإل شا ٖت انهًاابت ِانجّ ٗاث نههسجقبم.

Zagazig J. Forensic Med.& Toxicology Vol.(18) No. (2) July 2020