The role of forensic pathologists in coronavirus disease 2019 infection: The importance of an interdisciplinary research

Dear editor

We wish to highlight the importance of the role of forensic pathologists and the medico-legal implications of coronavirus disease 2019 (COVID-19) infections.

In the last few months of 2019, in China, many patients were hospitalised due to pneumonia of unknown aetiology. ¹ Several days later, Chinese health authorities confirmed that they had recognised a new type of severe acute respiratory syndrome coronavirus (SARS-CoV-2). The World Health Organization then stated that the COVID-19 outbreak had become a public-health emergency of international interest. ²

Person-to-person transmission can occur through direct contact – specifically, through droplets spread by sneezing or coughing. ¹ The onset of the disease can lead to the rapid progression of organ dysfunction and death in severe cases. ³ The leading measure to contain this growing global problem is through the isolation and quarantine of those at risk. However, one of the biggest problems we are facing is that many infected people are either asymptomatic or paucisymptomatic. Not only can this easily lead to the virus spreading, increasing the likelihood of infection, there is also a risk of COVID-19 infection with each case that comes to autopsy.

To date, we do not know if nasopharyngeal swabs can give false-negative outcomes after death. Within which post-mortem interval (PMI) can this test reach an appropriate level of certainty? The scientific studies currently available in the literature are not sufficient to understand post-mortem uses and limitations. However, in autopsy routine practice, nasopharyngeal swabs are always useful as a preliminary examination to obtain additional data about possible COVID-19 infection.

Autopsy cases from areas of an infectious outbreak should be performed in ‘safe’ autopsy rooms that follow recommendations for strict biosafety and infection control practices. The Centers for Disease Control and Prevention (CDC) recommendations of March 2020 would guarantee adequate protection for forensic pathologists as well as their collaborators. In a recent report, Barton et al. ⁴ explained a comprehensive procedure regarding how to perform autopsies in COVID-19 cases, as well as reporting the autopsy findings in cases of COVID-19. In another article, Hanley et al. ⁵ described the hazard group categorisation and pathological features in suspected COVID-19 cases.

In some countries, the main problem concerns the extremely low number of ‘safe’ autopsy rooms, according to recent scientific guides. For example, in Italy, the number of autopsy rooms available that are capable of preventing a COVID-19 infectious risk is very limited, resulting in a significant reduction in the number of autopsies being performed.

Beyond these technical obstacles, however, we also must emphasise the importance of autopsy examinations in cases of COVID-19 infections. It is a ‘new’ infection, and its pathological mechanism is still poorly understood. Post-mortem investigation can help us to understand the COVID-19 pathological mechanism. According to the literature, ⁶ coronaviruses are not always restricted to the respiratory tract but can also involve the central nervous system. An autopsy and histological examination could define the pathological aspects and the organ involvement. For example, in the past, autopsy studies on SARS cases^7,8 have been particularly important for understanding and defining the pathology. Moreover, post-mortem studies will help clarify the survival of the virus after death and offer a better understanding of the real dangers a forensic pathologist and their collaborators could face when they are in contact with an infected corpse. At present, it is not specifically known how much or how long the virus can remain active in a human cadaver.

We strongly urge all forensic pathologists to follow the CDC guidance for COVID-19 carefully (Collection and Submission of Postmortem Specimens from Deceased Persons with Known or Suspected COVID-19, March 2020). ⁹ In our opinion, the scientific community should indicate and publish a more detailed autopsy protocol, specifying all the procedures to be followed during macroscopic analysis, as well as the histological and immunohistochemical investigations to be performed.

Moreover, interdisciplinary research associations, including medico-legal experts as well as pathologists and virologists, are necessary. The international standard autopsy procedure should be applied by all pathologists in confirmed or probable COVID-19 infection cases.

Forensic pathologists should perform post-mortem microbiological tests to rule out or confirm a COVID-19 infection. In addition, a microbiological examination should be performed in all cases where histological examination shows that interstitial pneumonia is confirmed and in probable COVID-19 cases. However, post-mortem studies will be needed to clarify the reliability and limitation of microbiological results on autopsy.

Last but not least, the exponential intensification of a COVID-19 infection has caused intense difficulties in hospital management (i.e. due to overcrowding). The expansion of COVID-19 infections led to a huge imbalance between the clinical needs of the population and the actual availability of intensive care unit resources in Italy. These management difficulties will bring an increase in medico-legal disputes.