PATHOLOGICA Epub 2020 Mar 26 DOI: 10.32074/1591-951X-13-20 Guidelines Management of the corpse with suspect, probable or confirmed COVID-19 respiratory infection – Italian interim recommendations for personnel potentially exposed to material from corpses, including body fluids, in morgue structures and during autopsy practice Vittorio Fineschi1, Anna Aprile2, Isabella Aquila3, Mauro Arcangeli4, Alessio Asmundo5, Mauro Bacci6, Mariano Cingolani7, Luigi Cipolloni8, Stefano D’Errico9, Ilaria De Casamassimi1, Giulio Di Mizio3, Marco Di Paolo10, Martina Focardi11, Paola Frati1, Mario Gabbrielli12, Raffaele La Russa1, Aniello Maiese10, Federico Manetti1, Massimo Martelloni13, Elena Mazzeo14, Angelo Montana15, Margherita Neri16, Martina Padovano1, Vilma Pinchi17, Cristoforo Pomara15, Pietrantonio Ricci3, Monica Salerno15, Alessandro Santurro1, Matteo Scopetti1, Roberto Testi18, Emanuela Turillazzi10, Giuseppe Vacchiano19 on behalf of the Scientific Society of Hospital Legal Medicine of the National Health System (COMLAS), Filippo Crivelli20, Emanuela Bonoldi21, Fabio Facchetti22, Manuela Nebuloni23 Anna Sapino24,25; on behalf of the Italian Society of Anatomical Received and accepted: March 25, 2020 Pathology and Cytology (SIAPEC) Published online: March 26, 2020 1 Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Correspondence Italy; 2 Department of Molecular Medicine, Legal Medicine, University of Padua, Italy; 3 Institute of Legal Anna Sapino Medicine, University “Magna Graecia” of Catanzaro, Italy; 4 Department of Clinical Medicine, Public Health, Life SC Anatomia Patologica FPO-IRCCS, and Environmental Sciences, University of L’Aquila, Italy; 5 Departmental section of Legal Medicine “G. Martino”, Candiolo (Turin), Italy and Department of University of Messina, Italy; 6 Forensic and Sports Medicine Section, Department of Surgery and Biomedical Medical Sciences, University of Turin, Italy Science, University of Perugia, Italy; 7 Section of Legal Medicine, University of Macerata, Italy; 8 Department E-mail: [email protected] of Clinical and Experimental Medicine, Section of Forensic Pathology, University of Foggia, Ospedale Colonnello D’Avanzo, Foggia, Italy; 9 Department of Legal Medicine, University of Trieste, Italy; 10 Department Conflict of interest statement of Surgical Pathology, Medical, Molecular and Critical Area, University of Pisa, Italy; 11 Department of Health The Authors declare no conflict of interest. Sciences, Section of Forensic Medicine, University of Florence, Italy; 12 Department of Medicine, Surgery and Neuroscience, Santa Maria alle Scotte University Hospital of Siena, Italy; 13 Department of Legal Medicine, Azienda USL Toscana Nordovest, Lucca, Italy; 14 Department of Biomedical Sciences, Legal Medicine, University How to cite this article: Fineschi V, Aprile A, of Sassari, Italy; 15 Department of Medical Science, Surgical Science and advanced Technologies “G.F, Ingrassia”, Aquila I, et al. Management of the corpse with University of Catania, Italy; 16 Department of Morphology, Surgery and Experimental Medicine, Section of Legal suspect, probable or confirmed COVID-19 Medicine and LTTA Centre, University of Ferrara, Italy; 17 Department of Health Sciences, University of Florence, respiratory infection – Italian interim recom- Italy; 18 ASL “Città di Torino”, Regional Center for Prion Diseases (DOMP), Turin, Italy; 19 Department of Law, mendations for personnel potentially exposed Economics, Management and Quantitative Methods, University of Sannio, Benevento, Italy; 20 SCA Anatomia to material from corpses, including body flu- Patologica, ASST Valle Olona, Busto Arsizio, Italy; 21 SC Anatomia Istologia Patologica e Citogenetica, Grande ids, in morgue structures and during autopsy Ospedale Metropolitano Niguarda Milan, Italy; 22 UOC di Anatomia Patologica, ASST Spedali Civili di Brescia, practice. Pathologica Epub 2020 Mar 26. Italy; 23 Anatomia Patologica, ASST-FBF-Sacco, Dibic, UNIMI, Italy; 24 SC Anatomia Patologica FPO-IRCCS, https://doi.org/10.32074/1591-951X-13-20 Candiolo (Turin), Italy ; 25 Department of Medical Sciences, University of Turin, Italy © Copyright by Società Italiana di Anatomia Pato- logica e Citopatologia Diagnostica, Divisione Itali- ana della International Academy of Pathology Introduction OPEN ACCESS The COVID-19 (Coronavirus Disease-19) is the most urgent health This is an open access article distributed in accordance emergency worldwide and all professionals are called to give support in with the Creative Commons Attribution Non Commercial the diagnosis and treatment of patients affected by this disease. (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and The Scientific Society of Hospital Legal Medicine of the National Health license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, System (COMLAS) and the Italian Society of Anatomical Pathology and any changes made indicated, and the use is non-commercial. Cytology (SIAPEC) produced this document with the intent of offering a See: http://creativecommons.org/licenses/by-nc/4.0 technical support to professional involved in the autoptic activities during 2 V. Fineschi et al. the Severe Acute Respiratory Syndrome Coronavi- Purpose and field of application rus 2 (SARS-CoV-2) epidemic infection. Coronaviruses are a broad category of viruses known The classification of infectious hazards needs to be to cause diseases ranging from the common cold to periodically reviewed and updated in light of global ep- Middle Eastern Respiratory Syndrome (MERS) and idemiological trends. The categorization of infectious Acute Severe Respiratory Syndrome (SARS). Recent- biological agents provides for the attribution to hazard ly, a novel coronavirus (nCoV) was identified that had groups (Hazard Group 1-4) based on the probability of never previously been found in humans 1-3. causing disease in humans, the probability of spread- The viruses responsible for SARS include SARS- ing the infection in the community, the availability of CoV-2 (Severe Acute Respiratory Syndrome Coro- prophylactic or therapeutic measures 31. navirus 2); the disease caused by the new Corona- The Advisory Committee on Dangerous Pathogens virus is called COVID-19 (Coronavirus Disease-19) (ACDP) in early 2020 established a provisional clas- and represents a cluster of pneumonia that has spread sification of SARS-CoV-2 as an HG3 pathogen (Hazard to China and other countries of the world since 31 De- Group 3). In this regard, it should be emphasized that cember 2019 4-8. HG3 agents can cause serious diseases in humans Initial reports suggest that transmission occurs during and constitute a serious risk for professionals; the agent close contact with an infected subject, mainly through may spread in the community, but effective prophylac- respiratory droplets produced in the act of speaking, tic or therapeutic measures are usually available. The coughing or sneezing 9,10. Droplets can settle on the risks for personnel operating in the morgue facilities, in eyes, nose or mouth, as well as being inhaled by peo- most infections, are minimal when standard universal ple nearby. At present, long-distance aerial transmis- precautions for infection prevention are applied 32-35. sion from person to person is unlikely. The purpose of the operating procedure is, therefore, Common signs of infection include fever, cough and to indicate how to manage the bodies of suspect or breathing difficulties. In severe cases, the infection confirmed cases of COVID-19 in order to minimize the can cause pneumonia, severe acute respiratory risk of environmental contamination and the contagion syndrome, multi-organ dysfunction or failure, and of personnel involved in the process. According to this death 11-16. perspective, the document is intended to recommend: WHO, CDC and ECDC have provided clear details on • the preparation of standard operating procedures measures to prevent the spread of the virus 17-21. Stan- (SOP) for the containment of infectious risk; dard recommendations to prevent the spread of infec- • adequate conduct for carrying out activities and tion include regular hand washing, covering the mouth maneuvers at risk during autopsy checks on cases and nose when coughing or sneezing and avoiding of SARS-CoV-2 infection; close contact 22,23. • personal protective equipment (PPE) to be used in At the Italian national level, the extra- and intra-hos- daily practice; pital path of suspect or confirmed cases of COVID-19 • the optimal evaluation pathways for the diagnosis and the indications relating to the use of personal pro- of SARS-CoV-2 infection. tective equipment (PPE) by healthcare personnel are The present document is mainly aimed at staff serv- extensively defined 24-28. ing in morgues (health professionals, trainees, as In view of the limited scientific knowledge and evi- well as auxiliary, administrative and surveillance staff) dence on SARS-CoV-2 infection, it is therefore con- and must be applied to every death from COVID-19, sidered appropriate to proceed systematically with the whether suspect, probable or confirmed. management of COVID-19 cases 29,30, whether they are suspect, probable or confirmed, accepted at the morgue. Hence the need to condense the available Terms and definitions evidence on biological risk, individual protection and autopsy investigation with the aim of providing a prac-