Safe management of bodies of deceased persons with suspected or confirmed COVID-19: a rapid systematic review

A review on medical waste treatment in COVID-19 pandemics: Technologies, managements and future strategies

Since the outbreak of COVID-19 few years ago, the increasing of the number of medical waste has become a huge issue because of their harmful impact to environment. A major concern associated to the limitation of technologies for dealing with medical waste, especially conventional technologies, are overcapacities since pandemic occurs. Moreover, the outbreak of new viruses from post COVID-19 should become a serious attention to be prevented not only environmental issues but also the spreading of viruses to new pandemic near the future. The high possibility of an outbreak of new viruses and mutation near the future should be prevented based on the experience associated with the SARS-CoV-2 virus in the last 3 yr. This review presented information and strategies for handling medical waste during the outbreak of COVID-19 and post-COVID-19, and also information on the current issues related to technologies, such as incineration, pyrolysis/gasification, autoclaves and microwave treatment for the dealing with high numbers of medical waste in COVID-19 to prevent the transmission of SARS-CoV-2 virus, their advantages and disadvantages. Plasma technology can be considered to be implemented as an alternative technology to deal with medical waste since incinerator is usually over capacities during the pandemic situation. Proper treatment of specific medical waste in pandemics, namely face masks, vaccine vials, syringes, and dead bodies, are necessary because those medical wastes are mediums for transmission of the SARS-CoV-2 virus. Furthermore, emission controls from incinerator and plasma are necessary to be implemented to reduce the high concentration of CO2, NOx, and VOCs during the treatment. Finally, future strategies of medical waste treatment in the perspective of potential outbreak pandemic from new mutation viruses are discussed in this review paper.Implications: Journal of the air and waste management association may consider our review paper to be published. In this review, we give important information related to the technologies, managements and strategies for handling the medical waste and control the transmission of SARS-CoV-2 virus, starting from proper technology to control the high number of medical waste, their pollutants and many strategies for controlling the spreading of SARS-CoV-2 virus. Moreover, this review also describes some strategies associated with control the transmission not only the SARS-CoV-2 virus but also the outbreak of new viruses near the future.

Challenges of using body bags for COVID-19 deaths from the healthcare provider perspective - a qualitative study

BACKGROUND

During the COVID-19 pandemic, numerous issues regarding end-of-life care for COVID-19 patients have been discussed. Among these issues, challenges related to the use of body bags following the death of COVID-19 patients have been suggested. This study aimed to identify the challenges faced by healthcare professionals (HCPs) when using body bags after the death of patients infected with COVID-19 in medical settings.

METHODS

We conducted a qualitative descriptive study with semistructured in-depth interviews using inductive thematic analysis. From August to December 2021, we interviewed nurses and doctors who provided end-of-life care to COVID-19 patients focusing on their experiences with the use of body bags for the deceased.

RESULTS

Of the 25 interviewees who mentioned body bag use, 14 were nurses (56%) and 13 were women (52%). The mean interview length was 52.0 min (SD 9.6 min). Challenges associated with body bag use were classified into four themes with eight categories: preserving the dignity of the deceased, consideration for the bereaved saying a final goodbye to a loved one in a body bag, the physical and emotional impact on HCPs, and diverse opinions on body bag use.

CONCLUSION

Our findings include ethical concerns about the dignity of the deceased, empathy for the grief of bereaved families, and the emotional and physical distress experienced by HCPs struggling with the recommendation to use body bags based on limited evidence. The diverse perspectives of HCPs in this study highlight potential issues that developers should consider when formulating more appropriate and acceptable guidelines/guidance and policies.

Global dynamics of a compartmental model to assess the effect of transmission from deceased

During several epidemics, transmission from deceased people significantly contributed to disease spread, but mathematical analysis of this transmission has not been seen in the literature numerously. Transmission of Ebola during traditional burials was the most well-known example; however, there are several other diseases, such as hepatitis, plague or Nipah virus, that can potentially be transmitted from disease victims. This is especially true in the case of serious epidemics when healthcare is overwhelmed and the operative capacity of the health sector is diminished, such as seen during the COVID-19 pandemic. We present a compartmental model for the spread of a disease with an imperfect vaccine available, also considering transmission from deceased infected in general. The global dynamics of the system are completely described by constructing appropriate Lyapunov functions. To support our analytical results, we perform numerical simulations to assess the importance of transmission from the deceased, considering the data collected from three infectious diseases, Ebola virus disease, COVID-19, and Nipah fever.

High titers of infectious SARS-CoV-2 in corpses of patients with COVID-19

OBJECTIVES

The prolonged presence of infectious SARS-CoV-2 in deceased patients with COVID-19 has been reported. However, infectious virus titers have not been determined. Such information is important for public health, death investigation, and handling corpses. The aim of this study was to assess the level of SARS-CoV-2 infectivity in the corpses of patients with COVID-19.

METHODS

We collected 11 nasopharyngeal swabs and 19 lung tissue specimens from 11 autopsy cases with COVID-19 in 2021. We then investigated the viral genomic copy number by real-time reverse transcription-polymerase chain reaction and infectious titers by cell culture and virus isolation.

RESULTS

Infectious virus was present in six of 11 (55%) cases, four of 11 (36%) nasopharyngeal swabs, and nine of 19 (47%) lung specimens. The virus titers ranged from 6.00E + 01 plaque-forming units/ml to 2.09E + 06 plaque-forming units/g. In all cases in which an infectious virus was found, the time from death to discovery was within 1 day and the longest postmortem interval was 13 days.

CONCLUSION

The corpses of patients with COVID-19 may have high titers of infectious virus after a long postmortem interval (up to 13 days). Therefore, appropriate infection control measures must be taken when handling corpses.

Rate of shed of SARS COV-2 viral RNA from COVID-19 cadavers

BACKGROUND

At what rate does the RNA of SARS CoV-2 shed from cadavers? Although, there have been numerous studies which have demonstrated the persistence of the virus on dead bodies, there is a lack of conclusive evidence regarding the variation of viral RNA content in cadavers. This has led to a knowledge gap regarding the safe handling/management of COVID-19 decedents, posing a barrier in forensic investigations.

METHODS

In this study, we report the presence of RNA of SARS CoV-2 by real time RT-PCR, in nasopharyngeal swabs collected after death from two groups of bodies - one who died due to COVID-19 and the other who died due to other diagnoses. A prospective study on 199 corpses, who had tested positive for COVID-19 ante-mortem, was conducted at a tertiary care center. RNA testing was conducted at different time intervals (T1-T5).

RESULTS

112(56.3%) died primarily due to COVID-19 and 87(43.7%) died due to other diagnoses. 144(72.4%) were male and 55(27.6%) were female. A total of 115 (57.8%) tested positive for COVID-19 after death at different time points. The mean age was 50.7 ± 18.9 years and the length of hospitalization ranged from 1 to 50 days with a mean of 9.2 ± 7.6 days. Realtime RT-PCR positivity of SARS CoV-2 RNA decreases with time.

CONCLUSION

We observed that real time RT-PCR positivity, indicating viral RNA detection, decreases with time. Therefore, it is advisable to follow appropriate COVID-19 precautions to carry out scientific studies, medico-legal investigations and mortuary services on suspected/confirmed COVID-19 corpses.

SARS-CoV-2 viral load and replication in postmortem examinations

We examined 29 autopsy cases (investigated between October 2020 and February 2021) whose postmortem swabs tested positive for SARS-CoV-2. Twenty-two of 29 cases died while hospitalized (H), while the remaining 7 cases were not hospitalized (NH). Since we included only cases in which the time since death was known (excluding unwitnessed NH deaths), the interval between death and postmortem swab(s) was registered, with a mean NH value of 5.50 days and a mean H value of 3.98 days. The mean age of NH was 65 years, while H were older (mean age: 73 years). Twenty-eight nasopharyngeal and 27 lungs postmortem swabs were obtained and real-time reverse transcriptase‒polymerase chain reaction assay for total and replicative SARS-CoV-2 RNA and mRNA detection was performed. Although the mean death-postmortem swabs interval was higher in NH than in H, the mean viral load of NH was higher than that of H (2.53 × 10¹¹ copies/mL vs 9.31 × 10⁸ copies/mL). In 13/29 cases (6 NH and 7 H), indicators of active replication were found. The relationship between the presence of replicative mRNA and death without hospitalization and that between the minimum cycle threshold value of SARS-CoV-2 RNA and the cycle threshold value of replicative SARS-CoV-2 mRNA were found to be statistically significant (with respective P values of 0.013 and 0.000). Therefore, especially in NH, full compliance with guidelines on biological safety in the autopsy room is essential, and no autopsy can be performed on infected cases in a structure that does not meet the established safety criteria.

Do We Really Need Hazard Prevention at the Expense of Safeguarding Death Dignity in COVID-19?

To date, little is known regarding the transmission risks of SARS-CoV-2 infection for subjects involved in handling, transporting, and examining deceased persons with known or suspected COVID-19 positivity at the time of death. This experimental study aims to define if and/or how long SARS-CoV-2 persists with replication capacity in the tissues of individuals who died with/from COVID-19, thereby generating infectious hazards. Sixteen patients who died with/from COVID-19 who underwent autopsy between April 2020 and April 2021 were included in this study. Based on PMI, all samples were subdivided into two groups: 'short PMI' group (eight subjects who were autopsied between 12 to 72 h after death); 'long PMI' (eight subjects who were autopsied between 24 to 78 days after death). All patients tested positive for RT-PCR at nasopharyngeal swab both before death and on samples collected during post-mortem investigation. Moreover, a lung specimen was collected and frozen at -80 °C in order to perform viral culture. The result was defined based on the cytopathic effect (subjective reading) combined with the positivity of the RT-PCR test (objective reading) in the supernatant. Only in one sample (PMI 12 h), virus vitality was demonstrated. This study, supported by a literature review, suggests that the risk of cadaveric infection in cases of a person who died from/with COVID-19 is extremely low in the first hours after death, becoming null after 12 h after death, confirming the World Health Organization (WHO) assumed in March 2020 and suggesting that the corpse of a subject who died from/with COVID-19 should be generally considered not infectious.

Body Donation, Teaching, and Research in Dissection Rooms in Spain in Times of Covid-19

The state of alarm due to Covid-19 pandemic in Spain stopped all educational and most university research activities. The Spanish Anatomical Society (SAE) Consensus Expert Group on Body Donations piloted a study based on a questionnaire to know the status of body donations and dissection activities during the lockdown, as well as the future implications of Covid-19 pandemic for body donation programs and anatomy teaching. The questionnaire results show that Spanish Universities refused body donations and stopped all dissection research and teaching. The Covid-19 expected influence on anatomy teaching was referred to the increase in teaching workforce and resources required to apply the new safety measures to future practical activities, as well as to prepare and adapt teaching material for online-only programs. The application of reinforced safety measures was expected to be perceived by the respondent's students as a gain in teaching quality, while the transformation of the anatomy courses in online-only programs will be perceived as a quality decrease. The respondent's concerns about future institutional implications of the pandemic were related to increased costs of the adaptation of the facilities and the reinforced preventive measures, as well as the eventual decrease in donations. The complete lockdown applied to dissection rooms was not justified by scientific evidence and represented a break of the confidence deposed in the institutions by the donors. A consensus is required for the adoption of a renewed, comprehensive protocol for present and future body donations including the evidence Covid-19 pandemic has contributed to create.

Autopsies in pandemics - a perspective on barriers and benefits. Is it time for a revival?

Influenza virus and coronavirus pandemics regularly sweep the globe, at great cost of health and economy. Our aim was to conduct a PubMed search for autopsy studies on influenza and coronavirus to investigate the contribution of autopsies during pandemics, focussing on autopsy methods and procedures and the role of autopsy findings in pandemics. The retrieved autopsy studies generally relied on microscopy, polymerase chain reaction (PCR), immunostaining and electron microscopy. Most were small and reported on lung effects, including diffuse alveolar damage (DAD), pneumonia and tracheobronchitis. Antibiotic therapy has diminished a role for bacterial pneumonia, whereas obesity is an emerging risk factor. Autopsy studies have provided new insights into coronavirus disease 2019 (COVID-19) treatments like anti-coagulative therapy. Unfortunately, autopsies during pandemics are hampered by lack of guidelines, facilities and expertise for handling potentially infectious corpses and by widely varying recommendations for personal protective equipment and procedures. The Department of Forensic Pathology, at the Forensic Institute, at the University of Copenhagen in Denmark has, in collaboration with the Department of Pathology, Rigshospitalet, Copenhagen, initiated a prospective observational study on COVID-19-related deaths encompassing postmortem imaging, standardized autopsy procedures/reporting and extensive tissue sampling for histological, chemical, microbiological and genetic analysis. The study involves a diverse array of research groups at the University of Copenhagen, and the clinical field.

Post-Mortem Detection of SARS-CoV-2 RNA in Long-Buried Lung Samples

The Coronavirus Disease 19 (COVID-19) pandemic has caused an unexpected death toll worldwide. Even though several guidelines for the management of infectious corpses have been proposed, the limited number of post-mortem analyses during the pandemic has led to inaccuracies in the counting of COVID-19 deaths and contributed to a lack of important information about the pathophysiology of the SARS-CoV-2 infection. Due to the impossibility of carrying out autopsies on all corpses, the scientific community has raised the question of whether confirmatory analyses could be performed on exhumed bodies after a long period of burial to assess the presence of SARS-CoV-2 RNA. Post-mortem lung samples were collected from 16 patients who died from COVID-19 infection and were buried for a long period of time. A custom RNA extraction protocol was developed to enhance extraction of viral RNA from degraded samples and highly sensitive molecular methods, including RT-qPCR and droplet digital PCR (ddPCR), were used to detect the presence of SARS-CoV-2 RNA. The custom extraction protocol developed allowed us to extract total RNA effectively from all lung samples collected. SARS-CoV-2 viral RNA was effectively detected in all samples by both RT-qPCR and ddPCR, regardless of the length of burial. ddPCR results confirmed the persistence of the virus in this anatomical niche and revealed high viral loads in some lung samples, suggesting active infection at the time of death. To the best of our knowledge, this is the first study to demonstrate the persistence of SARS-CoV-2 viral RNA in the lung even after a long post-mortem interval (up to 78 days). The extraction protocol herein described, and the highly sensitive molecular analyses performed, could represent the standard procedures for SARS-CoV-2 detection in degraded lung specimens. Finally, the innovative results obtained encourage post-mortem confirmatory analyses even after a long post-mortem interval.

A dignified death: management of dead bodies during COVID-19

The emergence of coronavirus disease-2019 (COVID-19) has caused unprecedented challenge to manage the bodies of the dead. The disposal of the dead becomes a challenge as there is a shortage of coffins, and crematoriums are overwhelmed. A recent correspondence published in the Journal of Public Health highlighted the importance of performing the last rites in a time of COVID-19 pandemic. This paper argues that the bodies of those who have died because of COVID-19 should be treated with respect and dignity.

Guidelines for Mountain Rescue During the COVID-19 Pandemic: Official Guidelines of the International Commission for Alpine Rescue

Roy, Steven, Inigo Soteras, Alison Sheets, Richard Price, Kazue Oshiro, Simon Rauch, Don McPhalen, Maria Antonia Nerin, Giacomo Strapazzon, Myron Allen, Alistair Read, and Peter Paal. Guidelines for mountain rescue during the COVID-19 pandemic: official guidelines of the International Commission for Alpine Rescue. High Alt Med Biol. 22: 128-141, 2021. Background: In mountain rescue, uncertainty exists on the best practice to prevent coronavirus disease 2019 (COVID-19) transmission. The aim of this work was to provide a state-of-the-art overview of the challenges caused by the COVID-19 pandemic in mountain rescue. Methods: Original articles or reviews, published until December 27, 2020 in Cochrane COVID-19 Study Register, EMBASE, PubMed, and Google Scholar were included. Articles were limited to English, French, German, or Spanish with the article topic COVID-19 or other epidemics, addressing transmission, transport, rescue, or cardiopulmonary resuscitation. Results: The literature search yielded 6,190 articles. A total of 952 were duplicates and 5,238 were unique results. After exclusion of duplicates and studies that were not relevant to this work, 249 articles were considered for this work. Finally, 72 articles and other sources were included. Conclusions: Recommendations are provided for protection of the rescuer (including screening, personal protective equipment [PPE], and vaccination), protection of the patient (including general masking if low risk, specific PPE if high risk), equipment hygiene (including disinfection after every mission), use of single-use products, training and medical measures under COVID-19 precautions, and psychological wellbeing of rescuers during the COVID-19 pandemic. Adapted COVID-19 precautions for low-and-medium-income countries are also discussed.

Laboratory medicine in the COVID-19 era: six lessons for the future

The lockdown due to the coronavirus disease 2019 (COVID-19), a major healthcare challenge, is a worldwide threat to public health, social stability, and economic development. The pandemic has affected all aspects of society, dramatically changing our day-to-day lives and habits. It has also changed clinical practice, including practices of clinical laboratories. After one year, it is time to rethink what has happened, and is still happening, in order to learn lessons for the future of laboratory medicine and its professionals. While examining this issue, I was inspired by Italo Calvino's famous work, "Six memos for the next millennium".But I rearranged the Author's six memos into "Visibility, quickness, exactitude, multiplicity, lightness, consistency".

Opinion on the practice of cremation funeral for patients who died of COVID-19

During the early phase of coronavirus disease 2019 (COVID-19) pandemic, South Korea was among the countries affected by the novel infectious disease soon after China. A year later, South Korea is considered one of the countries to have successfully responded to COVID-19. Even though South Korea has struggled to learn how to live wisely with COVID-19, much less effort has been put into learning how to die gracefully during the COVID-19 pandemic. From the beginning of the pandemic, the Korean government has recommended (or mandated) cremation for those who die from COVID-19 to prevent further spread of the disease. However, the World Health Organization has announced that corpses are generally not contagious and cremation should be a matter of culture choice and available resources. In South Korea, the government pays compensation to the families of the deceased because they follow the national guidelines for the cremation and disinfection of bodies. However, it is now time to discuss how to support the families of the deceased, helping them to safely grieve and honor their loved one in their own ways, rather than forcing them to wrap the deceased with a plastic bag and proceed with a hasty cremation.

Pathological Findings in COVID-19 as a Tool to Define SARS-CoV-2 Pathogenesis. A Systematic Review

Introduction: The World Health Organization declared the COVID-19 pandemic in March 2020. COVID-19 still represents a worldwide health emergency, which causesa severe disease that has led to the death of many patients. The pathophysiological mechanism of SARS-CoV-2 determining the tissue damage is not clear and autopsycan be auseful tool to improve the knowledge of this infection and, thus, it can help achieve a timely diagnosis and develop an appropriate therapy. This is an overview of the main post-mortem findings reporting data on the infection effects on several organs. Methods: A systematic literature search was conducted in the PubMed database searching for articles from 1 January to August 31, 2020. Thearticles were selected identifying words/concepts in the titles and/or abstracts that indicated the analysis of the morphological/pathological tissue injuries related to SARS-CoV-2 disease by several investigations. Results: A total of 63 articles were selected. The main investigated tissue was the lung showing a diffuse alveolar damage (DAD) frequently associated with pulmonary thrombotic microangiopathy. Inflammatory findings and vascular damage were observed in other organs such as heart, liver, kidney, brain, spleen, skin and adrenal gland. The immunohistochemical analysis showed tissue inflammatory cells infiltrates. The virus presence was detected by several investigations such as RT-PCR, immunohistochemistry and electron microscope, showing the effect ofSARS-CoV-2not exclusively in the lung. Discussion: The evidence emerging from this review highlighted the importance of autopsy to provide a fundamental base in the process of understanding the consequences ofSARS-CoV-2 infection. COVID-19 is strictly related to a hyper inflammatory state that seems to start with DAD and immuno-thrombotic microangiopathy. Massive activation of the immune system and microvascular damage might also be responsible for indirect damage to other organs, even if the direct effect of the virus on these tissues cannot be excluded.

Kenya's response to the COVID-19 pandemic: a balance between minimising morbidity and adverse economic impact

Coronavirus disease 2019 (COVID-19) has ravaged the world's socioeconomic systems forcing many governments across the globe to implement unprecedented stringent mitigation measures to restrain its rapid spread and adverse effects. A disproportionate number of COVID-19 related morbidities and mortalities were predicted to occur in Africa. However, Africa still has a lower than predicted number of cases, 4% of the global pandemic burden. In this open letter, we highlight some of the early stringent countermeasures implemented in Kenya, a sub-Saharan African country, to avert the severe effects of the COVID-19 pandemic. These mitigation measures strike a balance between minimising COVID-19 associated morbidity and fatalities and its adverse economic impact, and taken together have significantly dampened the pandemic's impact on Kenya's populace.

Current perspectives of biomedical waste management in context of COVID-19"

COVID-19 pandemic and it's consequent biomedical waste is an unprecedented challenge worldwide. Biomedical waste generated during COVID-19 patient isolation, testing and care needs special consideration as it challenges the previous notion that only 15-20% of waste can be considered infectious. With establishment of new home quarantine facility, isolation/quarantine centres the chances of general waste getting contaminated with biomedical waste has increased exponentially. Through this systematic review the authors searched for all possible queries raised by different researchers on COVID19 waste management on Pubmed. A summary of all the different issues unique to COVID19 waste was prepared. Guidelines, rules and recommendation given by national and international agencies published till date were taken into account while trying to answer all the above questions raised by different studies. The key step in COVID19 waste management is segregation of biomedical waste from solid waste. Waste generated from COVID19 patients is like any other infectious waste, therefore creating public awareness about the COVID19 waste hazards and segregation at source is highlighted in all guidelines as a recommendation. These guidelines for management of waste generated during diagnostics and treatment of COVID-19 suspected or confirmed patients, are required to be followed in addition to existing practices under regulation. BMWM in COVID-19 context is a public health concern and is both a legal and social responsibility for all stakeholders.

Text mining approaches for dealing with the rapidly expanding literature on COVID-19

More than 50 000 papers have been published about COVID-19 since the beginning of 2020 and several hundred new papers continue to be published every day. This incredible rate of scientific productivity leads to information overload, making it difficult for researchers, clinicians and public health officials to keep up with the latest findings. Automated text mining techniques for searching, reading and summarizing papers are helpful for addressing information overload. In this review, we describe the many resources that have been introduced to support text mining applications over the COVID-19 literature; specifically, we discuss the corpora, modeling resources, systems and shared tasks that have been introduced for COVID-19. We compile a list of 39 systems that provide functionality such as search, discovery, visualization and summarization over the COVID-19 literature. For each system, we provide a qualitative description and assessment of the system's performance, unique data or user interface features and modeling decisions. Many systems focus on search and discovery, though several systems provide novel features, such as the ability to summarize findings over multiple documents or linking between scientific articles and clinical trials. We also describe the public corpora, models and shared tasks that have been introduced to help reduce repeated effort among community members; some of these resources (especially shared tasks) can provide a basis for comparing the performance of different systems. Finally, we summarize promising results and open challenges for text mining the COVID-19 literature.

SARS-CoV-2 infection in mortuary and cemetery workers

BACKGROUND

Mortuary and cemetery workers may be exposed to the bodies of people with SARS-CoV-2 infection; however, prevalence of infection among these groups is unknown.

METHODS

Nasopharyngeal swabs (NPS) for RT-PCR and serologic testing for SARS-CoV-2 were performed on mortuary and cemetery workers in Qatar. Data on specific job duties, living conditions, contact history, and clinical course were gathered. Environmental sampling was carried out to explore any association with infection. Logistic regression analysis was used to determine the factors associated with infection.

RESULTS

Forty-seven mortuary workers provided an NPS and seven (14.9%) were PCR positive; 32 provided a blood sample and eight (25%) were antibody positive, six (75%) who were seropositive were also PCR positive. Among the 81 cemetery workers, 76 provided an NPS and five (6.6%) were PCR positive; 64 provided a blood sample and 22 (34.4%) were antibody positive, three (13.6%) who were seropositive were also PCR positive. Three (22.2%) and 20 (83.3%) of the infected mortuary and cemetery workers were asymptomatic, respectively. Age <30 years (OR 4.9, 95% CI 1.7-14.6), community exposure with a known case (OR 4.7, 95% CI 1.7-13.3), and presence of symptoms in the preceding 2 weeks (OR 9.0, 95% CI 1.9-42.0) were independently associated with an increased risk of infection (PCR or antibody positive). Of the 46 environmental and surface samples, all were negative or had a Ct value of >35.

CONCLUSION

A substantial proportion of mortuary and cemetery workers had evidence of SARS-CoV-2 infection, which was incidentally detected upon serologic testing. These data are most consistent with community acquisition rather than occupational acquisition.

Safe Management Strategies in Clinical Forensic Autopsies of Confirmed COVID-19 Cases

To date, there is poor evidence on the transmission of infection in individuals handling the bodies of deceased persons infected with SARS-CoV-2 and in particular, during autopsies. The aim of this study was to demonstrate that when appropriate strategies are adopted autopsy is a safe procedure with a minimal infection risk for all subjects involved (pathologists, technical personnel, and others) when proper strategies are adopted. We performed 16 autopsies on cadavers of persons who had died with confirmed COVID-19 with different post-mortem intervals (PMI). To confirm the presence of SARS-CoV-2 RNA, for each autopsy, 2 swabs were sampled from lungs, while to evaluate environmental contamination, 11 swabs were taken at three different times: T0 (before autopsy), T1 (at the end of the autopsy, without removing the corpse), and T2 (after cleaning and disinfecting the autopsy room). Specifically, 2 swabs were sampled on face shields used by each pathologist, and 4 swabs were collected on the autopsy table; 4 swabs were also collected from walls and 1 from floor. Lung swabs confirmed the presence of SARS-CoV-2 RNA in all cases. Environmental swabs, collected at T0 and T2 were all negative, while swabs sampled at T1 were shown to be positive. Interestingly, no association was shown between PMI length and environmental contamination. Infection control strategies for safe management of clinical forensic autopsies of bodies with suspected or confirmed COVID-19 are also described.

The Cadaver Conundrum: Sourcing and Anatomical Embalming of Human Dead Bodies by Medical Schools during and after COVID-19 Pandemic: Review and Recommendations

COVID-19 pandemic has posed a new challenge for medical schools across the world regarding the acceptance of donated and unclaimed dead bodies for academic purpose. Uncertainty of the COVID-19 status among the donated bodies poses a health risk for embalming personnel and medical students who handle the embalmed cadavers. There is a paucity of literature delineating the criteria for accepting or rejecting the bodies during COVID-19 pandemic. Similarly, there is no recommended standard operating procedure for anatomical embalming during COVID-19. We propose certain criteria for accepting and rejecting the human dead bodies for anatomical embalming. And we propose some technical modifications to the conventional procedure of formalin-based anatomical embalming. A guarded approach and diligent screening of donated bodies is the way forward during the COVID-19 pandemic.

Kenya's response to the COVID-19 pandemic: a balance between minimising morbidity and adverse economic impact

Coronavirus disease 2019 (COVID-19) has ravaged the world's socioeconomic systems forcing many governments across the globe to implement unprecedented stringent mitigation measures to restrain its rapid spread and adverse effects. A disproportionate number of COVID-19 related morbidities and mortalities were predicted to occur in Africa. However, Africa still has a lower than predicted number of cases, 4% of the global pandemic burden. In this open letter, we highlight some of the early stringent countermeasures implemented in Kenya, a sub-Saharan African country, to avert the severe effects of the COVID-19 pandemic. These mitigation measures strike a balance between minimising COVID-19 associated morbidity and fatalities and its adverse economic impact, and taken together have significantly dampened the pandemic's impact on Kenya's populace.

Human anatomy education and management of anatomic specimens during and after COVID-19 pandemic: Ethical, legal and biosafety aspects

COVID-19 is an infection caused by the SARS-CoV-2 virus, initially identified in the city of Wuhan, China, in December 2019. Since then, the virus has spread to the continents, causing a major pandemic. The impacts of this pandemic on the education of human anatomy interfere in at least two aspects: (1) receiving and managing anatomical specimens in anatomy laboratories and (2) adaptations for classes on remote virtual teaching. Therefore, this study reviewed and discussed the legal and bioethical aspects, considering the scenario of a South American Country, aiming to stimulate the debate on these two relevant themes in the international community. Because of the COVID-19 pandemic and the impossibility of mass testing, anatomists and other workers in the field must deal with the risk of receiving bodies infected with SARS-CoV-2. In this situation, additional care measures in biosafety practices are essential to protect the staff. Such measures are: the bodies must be preserved by the perfusion of formaldehyde or other fixative solutions; embalming must be performed in ventilated rooms with a good air exhaust system; to avoid excessive manipulation of bodies and procedures such as pulmonary insufflation or craniotomy; and proper use of personal protective equipment, including lab coat, gloves and masks. As for exposure of body images in online classes, this review showed that there are no legal impediments to this end. However, anatomists must adopt measures aimed at protecting the memory of the deceased, such as using secure digital platforms with restricted access; family authorization/consent and student awareness.

Perils of human remains examination in COVID-19 times

The novel coronavirus, SARS-CoV-2 has surged globally bringing the whole world virtually to a standstill. Due to its highly contagious nature, various guidelines, protocols and preventive strategies have been devised for the safety of healthcare workers during management of the living as well as the dead. However, guidelines and precautions to be followed during the examination of the human skeletal remains are largely lacking. The present communication intends to address the issue of safe handling of human remains during medicolegal investigations in the COVID-19 pandemic times.

Considerations of coronavirus (COVID-19) impact and the management of the dead in Brazil

During a pandemic such as COVID-19, the forensic community plays a key role in the management of the crisis, both nationally and internationally. Much has been written and disseminated regarding protocols for death investigation, infection mitigation and risks, and management of dead. However, in many contexts, the ability of forensic practitioners to follow best-practice procedures is limited by the resources available to them. This article examines some of the impact of the novel coronavirus (COVID-19) in Brazil, with emphasis on management of the dead and challenges faced by medicolegal services.

The clinical value of minimal invasive autopsy in COVID-19 patients

BACKGROUND

Minimally invasive autopsy (MIA) is a validated and safe method to establish the cause of death (COD), mainly in low-resource settings. However, the additional clinical value of MIA in Coronavirus disease (COVID-19) patients in a high-resource setting is unknown. The objective was to assess if and how MIA changed clinical COD and contributing diagnoses in deceased COVID-19 patients.

METHODS AND FINDINGS

A prospective observational cohort from April to May 2020 in a 981-bed teaching hospital in the epicenter of the COVID-19 pandemic in Belgium was established. Patients who died with either PCR-confirmed or radiologically confirmed COVID-19 infection were consecutively included. MIA consisted of whole-body CT and CT-guided Tru-Cut® biopsies. Diagnostic modalities were clinical chart review, radiology, microbiology, and histopathology which were assessed by two independent experts per modality. MIA COD and contributing diagnoses were established during a multi-disciplinary meeting. Clinical COD (CCOD) and contributing diagnosis were abstracted from the discharge letter. The main outcomes were alterations in CCOD and contributing diagnoses after MIA, and the contribution of each diagnostic modality. We included 18 patients, of which 7 after intensive care unit hospitalization. MIA led to an alteration in 15/18 (83%) patients. The CCOD was altered in 5/18 (28%) patients. MIA found a new COD (1/5), a more specific COD (1/5), a less certain COD (1/5), or a contributing diagnosis to be the COD (2/5). Contributing diagnoses were altered in 14/18 (78%) patients: 9 new diagnoses, 5 diagnoses dismissed, 3 made more specific, and 2 made less certain. Overall, histopathology contributed in 14/15 (93%) patients with alterations, radiology and microbiology each in 6/15 (40%), and clinical review in 3/15 (20%). Histopathology was deemed the most important modality in 10 patients, radiology in two patients, and microbiology in one patient.

CONCLUSION

MIA, especially histological examination, can add valuable new clinical information regarding the cause of death in COVID-19 patients, even in a high-resource setting with wide access to premortem diagnostic modalities. MIA may provide important clinical insights and should be applied in the current ongoing pandemic.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT04366882.

Autopsy Services and Emergency Preparedness of a Tertiary Academic Hospital Mortuary for the COVID-19 Public Health Emergency: The Yale Plan

Pathology Autopsy and Mortuary Services have been front and center in the severe acute respiratory syndrome coronavirus 2 (SARS-Co-V-2) pandemic. The sheer number of fatalities from the pandemic have been unlike any other in recent memory and needed the rapid creation of new protocols and paradigms to manage the situation. This required rapidly escalating mortuary capacity to manage the increased fatalities from the pandemic with the establishment of lines of communication and networking with governmental entities, institution of new policies for patient flow, and implementation of worker infection control and well-being plans. Autopsies also assumed a crucial role, both to provide insight into the pathomechanisms of a novel disease and to allow tissue retrieval necessary to power research directed towards finding a vaccine. We here outline the plan adopted by the Yale Autopsy and Mortuary Services, in alignment with the institutional mission of high-quality patient care, education, research and health care worker safety and well-being, as the Corona Virus Disease of 2019 (COVID-19) pandemic surged in Connecticut. In the early response phase, ensuring sufficient mortuary capacity necessarily took center stage. As we enter the recovery and plateau phase of the pandemic, setting up a process for a rapid and safe autopsy, that will meet educational and research needs while ensuring the safety of our workforce is being implemented.

Using GRADE in situations of emergencies and urgencies: certainty in evidence and recommendations matters during the COVID-19 pandemic, now more than ever and no matter what

OBJECTIVES

The public, policy makers, and science communities are subject to many false, uninformed, overly optimistic, premature, or simply ridiculous health claims. The coronavirus disease 2019 (COVID-19) pandemic and its context is a paramount example for such claims. In this article, we describe why expressing the certainty in evidence to support a decision is critical and why the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach matters now, perhaps more than ever and no matter what the specific topic is in relation to COVID-19. We finally also offer suggestions for how it can be used appropriately to support decision-making at global, national, and local level when emergency, urgent or rapid responses are needed.

STUDY DESIGN AND SETTING

This is an invited commentary to address the objectives above building on examples from the recent COVID-19 pandemic. This includes an iterative discussion of examples and development of guidance.

RESULTS

The GRADE approach is a transparent and structured method for assessing the certainty of evidence and when developing recommendations that requires little additional time. We describe why emergency, urgent, or rapid responses do not justify omitting this critical assessment of the evidence. In situations of emergencies and urgencies, such as the COVID-19 pandemic, GRADE can similarly be used to express and convey certainty in intervention effects, test accuracy, risk and prognostic factors, consequences of public health measures, and qualitative bodies of evidence.

CONCLUSIONS

Assessing and communicating the certainty of evidence during the COVID-19 pandemic is critical. Those offering evidence synthesis or making recommendations should use transparent ratings of the body of evidence supporting a claim regardless of time that is available or needed to provide this response.

COVID-19: Biosafety in the Intensive Care Unit

PURPOSE OF REVIEW

COVID-19 is a new, highly transmissible disease to which healthcare workers (HCWs) are exposed, especially in the intensive care unit (ICU). Information related to protection mechanisms is heterogeneous, and the infected HCWs' number is increasing. This review intends to summarize the current knowledge and practices to protect ICU personnel during the patient management process in the context of the current pandemic.

RECENT FINDINGS

The transmission mechanisms of SARS-CoV-2 are mainly respiratory droplets, aerosols, and contact. The virus can last for a few hours suspended in the air and be viable on surfaces for several days. Some procedures carried out in the ICU can generate aerosols. The shortage of respirators, such as the N95, has generated an increase in the demand for other protective equipment in critical care settings.

SUMMARY

The probability of transmission depends on the characteristics of the pathogen, the availability of quality personal protective equipment, and the human factors associated with the performance of health workers. It is necessary to have knowledge of the virus and availability of the best possible personal protection equipment, develop skills for handling equipment, and develop non-technical skills during all intensive care process; this can be achieved through structured training.

Preliminary Post-Mortem COVID-19 Evidence of Endothelial Injury and Factor VIII Hyperexpression

(1) Background: The current outbreak of COVID-19 infection is an ongoing challenge and a major threat to public health that requires surveillance, prompt diagnosis, as well as research efforts to understand the viral pathogenesis. Despite this, to date, very few studies have been performed concerning autoptic specimens. Therefore, this study aimed: (i) to reiterate the importance of the autoptic examination, the only method able to precisely define the cause of death; (ii) to provide a complete post-mortem histological and immunohistochemical investigation pattern capable of diagnosing death from COVID-19 infection. (2) Methods: In this paper, the lung examination of two subjects who died from COVID-19 are discussed, comparing the obtained data with those of the control, a newborn who died from pneumonia in the same pandemic period. (3) Results: The results of the present study suggest that COVID-19 infection can cause different forms of acute respiratory distress syndrome (ARDS), due to diffuse alveolar damage and diffuse endothelial damage. Nevertheless, different patterns of cellular and cytokine expression are associated with anti-COVID-19 antibody positivity, compared to the control case. Moreover, in both case studies, it is interesting to note that COVID-19, ACE2 and FVIII positivity was detected in the same fields. (4) Conclusions: COVID-19 infection has been initially classified as exclusively interstitial pneumonia with varying degrees of severity. Subsequently, vascular biomarkers showed that it can also be considered a vascular disease. The data on Factor VIII discussed in this paper, although preliminary and limited in number, seem to suggest that the thrombogenicity of Sars-CoV2 infection might be linked to widespread endothelial damage. In this way, it would be very important to investigate the pro-coagulative substrate both in all subjects who died and in COVID-19 survivors. This is because it may be hypothesized that the different patterns with which the pathology is expressed could depend on different individual susceptibility to infection or a different personal genetic-clinical background. In light of these findings, it would be important to perform more post-mortem investigations in order to clarify all aspects of the vascular hypothesis in the COVID-19 infection.

Support for families of isolated or deceased COVID-19 patients in sub-Saharan Africa

Aside the direct effect of the COVID-19 on infected patients, this infectious disease outbreak has various psychological consequences. These mental health repercussions pertain to the general population of uninfected individuals, and particularly families of isolated or deceased COVID-19 patients. This aspect is of substantial interest amid sub-Saharan African communities, considering the key place and cultural significance of mourning and funerals in these settings. In this commentary, we discuss on the issue of psychological and social support of COVID-19 patients' families, by taking into account some sub-Saharan African cultural considerations.

Clinical-Forensic Autopsy Findings to Defeat COVID-19 Disease: A Literature Review

The severe acute respiratory syndrome (SARS)-CoV-2 was identified for the first time in China, in December 2019. Confirmed cases of COVID-19 have been reported around the world; indeed, this infection has been declared a pandemic. Consequently, the scientific community is working hard to gain useful information about the history of this virus, its transmission, diagnosis, clinical features, radiological findings, research and development of candidate therapeutics as well as vaccines. This review aims to analyze the diagnostic techniques used to ascertain the COVID-19 infection, critically reviewing positive points and criticism for forensic implications, obviously including autopsy. Finally, this review proposes a practical workflow to be applied in the management of corpses during this outbreak of the COVID-19 infection, which could be useful in cases of future infectious disease emergencies. Analyzing the diagnostic methods, to date, virus nucleic acid RT-PCR represents the standard method used to ascertain the COVID-19 infection in living subjects and corpses, even if this technique has several criticisms: mainly, the staff should be highly specialized, working in high-throughput settings, able to handle high workloads and aware of health risks and the importance of the results. Thus, IgG/IgM serological tests have been developed, overcoming RT-qPCR duration, costs, and management, not requiring highly trained personnel. Nevertheless, serological tests present problems; the WHO recommends the use of these new point-of-care immunodiagnostic tests only in research settings. Furthermore, nothing has yet been published regarding the possibility of applying these methods during post-mortem investigations. In light of this scenario, in this review, we suggest a flow chart for the pathologist called on to ascertain the cause of death of a subject with historical and clinical findings of COVID-19 status or without any anamnestic, diagnostic, or exposure information. Indeed, the literature data confirmed the analytical vulnerabilities of the kits used for laboratory diagnosis of COVID-19, particularly during postmortem examinations. For these reasons, autopsy remains the gold standard method to ascertain the exact cause of death (from or with COVID-19 infection, or other causes), to consequently provide real data for statistical evaluations and to take necessary measures to contain the risks of the infection. Moreover, performing autopsies could provide information on the pathogenesis of the COVID-19 infection with obvious therapeutic implications.

CORD-19: The Covid-19 Open Research Dataset

The Covid-19 Open Research Dataset (CORD-19) is a growing resource of scientific papers on Covid-19 and related historical coronavirus research. CORD-19 is designed to facilitate the development of text mining and information retrieval systems over its rich collection of metadata and structured full text papers. Since its release, CORD-19 has been downloaded over 200K times and has served as the basis of many Covid-19 text mining and discovery systems. In this article, we describe the mechanics of dataset construction, highlighting challenges and key design decisions, provide an overview of how CORD-19 has been used, and describe several shared tasks built around the dataset. We hope this resource will continue to bring together the computing community, biomedical experts, and policy makers in the search for effective treatments and management policies for Covid-19.