Health and safety at necropsy

A Study of Mycobacterium tuberculosis Detection Using Different Neural Networks in Autopsy Specimens

Tuberculosis (TB) presents a substantial health risk to autopsy staff, given its three to five times higher incidence of TB compared to clinical staff. This risk is notably accentuated in South Korea, which reported the highest TB incidence rate and the third highest TB mortality rate among OECD member countries in 2020. The standard TB diagnostic method, histopathological examination of sputum or tissue for acid-fast bacilli (AFB) using Ziehl-Neelsen staining, demands microscopic examination of slides at 1000× magnification, which is labor-intensive and time-consuming. This article proposes a computer-aided diagnosis (CAD) system designed to enhance the efficiency of TB diagnosis at magnification less than 1000×. By training nine neural networks with images taken from 30 training slides and 10 evaluation slides at 400× magnification, we evaluated their ability to detect M. tuberculosis. The N model achieved the highest accuracy, with 99.77% per patch and 90% per slide. We discovered that the model could aid pathologists in preliminary TB screening, thereby reducing diagnostic time. We anticipate that this research will contribute to minimizing autopsy staff's infection risk and rapidly determining the cause of death.

Risk of occupational infection in forensic workers: a review

The occupational risk of infection in forensic workers is a cause for concern, furthermore in the current context of the coronavirus disease-19 (COVID-19) pandemic. In order to characterize this risk, we performed an extended review of the literature on occupational infections occurring in forensic workers. Seventeen articles were included. Direct contamination by aerosolization was the main mode of transmission reported, with 17 cases of tuberculosis. Indirect contamination was described as the mode of transmission in 10 cases (five cases of blastomycosis, two cases of tuberculosis, two Streptococcus pyogenes, and one case of human immunodeficiency virus). In all the other included cases, the mode of transmission was unknown. For two of them, the information provided was sufficient to link them to occupational exposure (one case of toxoplasmosis, one case of tuberculosis). For the remaining 10 cases, the link was uncertain (six cases of tuberculosis, three of hepatitis B, and one of COVID-19). Even if there is probably significant under-declaration, the number of infections linked to an occupational risk in forensic workers is not alarming, thanks to effective preventive measures.

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.

Workplace hazards in forensic mortuaries in Saudi Arabia: A survey of forensic mortuary personnel

Forensic mortuaries have always presented a potential threat to workers who come into contact with dead bodies. This research aims to identify hazards faced by forensic mortuary personnel, including forensic pathologists and technicians working in forensic mortuaries in forensic medicine centres throughout Saudi Arabia, to recognise the prevalence of exposure to workplace hazards and to discover the degree of awareness and use of safety practices. A descriptive, cross-sectional study was conducted in a total of 20 forensic medicine centres, using an online questionnaire distributed among forensic mortuary personnel. A total of 113 participants responded to the questionnaire. Just over half (53%) of workplaces always provided personal protective equipment, and 75% of participants always used them. The most common hazards were needle-prick wounds and accidental slips or falls. Almost two thirds (64%) of participants witnessed or experienced a work-related accident in the forensic mortuary. The lack of previous studies concerning hazard exposure among forensic mortuary personnel in Saudi Arabia means that this study provides foundational evidence for future research concerning forensic autopsy-related work accidents in Saudi Arabia.

Mapping Biological Risks Related to Necropsy Activities: Old Concerns and Novel Issues for the Safety of Health Professionals

Nowadays only a few studies on biological and environmental risk among healthcare workers are available in literature. The present study aims to assess the health operator’s risk of contact with microorganisms during necropsy activities, to evaluate the efficiency of current protections, to identify possible new sources of contact, and to point out possible preventive measures. In addition, considering the current pandemic scenario, the risk of transmission of SARS-CoV-2 infection in the dissection room is assessed. The objectives were pursued through two distinct monitoring campaigns carried out in different periods through sampling performed both on the corpses and at the environmental level.

Evaluation of Physical Risk during Necropsy and Morgue Activities as Risk Management Strategy

Physical risk assessments allow us to understand work-related critical issues, thus representing a useful tool in risk management strategies. In particular, our study focuses on the identification of already known and emerging physical risks related to necropsy and morgue activities, as well as crime scene investigations. The aim of our study is, therefore, to identify objective elements in order to quantify exposure to such risk factors among healthcare professionals and working personnel. For the research of potentially at-risk activities, data from the Morgue of Policlinico Umberto I Hospital in Rome were used. The scientific literature has been reviewed in order to assess the risks associated with morgue activity. Measurements were performed on previously scheduled days, in collaboration with the activities of different research units. The identified areas of risk were: microclimate; exposure to noise and vibrations; postural and biomechanical aspects of necropsy activities. The obtained results make it possible to detect interindividual variability in exposure to many of the aforementioned risk factors. In particular, the assessment of microclimate did not show significant results. On the contrary, exposure to vibrations and biomechanical aspects of load handling have shown potential risk profiles. For this reason, both profiles have been identified as possible action targets for risk management strategies.

Post-mortem persistence of SARS-CoV-2: a preliminary study

Since the beginning of March 2020, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been the cause of millions of deaths worldwide. The need to better define the pathogenesis of coronavirus disease 19 (Covid-19) as well as to provide the correct statistical records concerning deaths related to this virus, inevitably involves the role of forensic pathology and routine autopsy practice. Currently, some data on macroscopic and microscopic features in autopsies performed in suspected Covid-19 cases are reported in the literature. The persistence of SARS-CoV-2 in cadavers has not yet been elucidated and only a few reports have emphasized the importance of evaluating the Virus RNA in post-mortem tissues. In this preliminary study, we observed that SARS-CoV-2 survives in multiple cadaver tissues many days after death despite some extreme conditions of post-mortem body preservation. The results of this on-going analysis could help improve the safety of working practices for pathologists as well as understanding the possible interaction between microbiological agents and the cadaver tissue's supravital reactions.

Simplicial SIRS epidemic models with nonlinear incidence rates

Mathematical epidemiology that describes the complex dynamics on social networks has become increasingly popular. However, a few methods have tackled the problem of coupling network topology with complex incidence mechanisms. Here, we propose a simplicial susceptible-infected-recovered-susceptible (SIRS) model to investigate the epidemic spreading via combining the network higher-order structure with a nonlinear incidence rate. A network-based social system is reshaped to a simplicial complex, in which the spreading or infection occurs with nonlinear reinforcement characterized by the simplex dimensions. Compared with the previous simplicial susceptible-infected-susceptible (SIS) models, the proposed SIRS model can not only capture the discontinuous transition and the bistability of a complex system but also capture the periodic phenomenon of epidemic outbreaks. More significantly, the two thresholds associated with the bistable region and the critical value of the reinforcement factor are derived. We further analyze the stability of equilibrium points of the proposed model and obtain the condition of existence of the bistable states and limit cycles. This work expands the simplicial SIS models to SIRS models and sheds light on a novel perspective of combining the higher-order structure of complex systems with nonlinear incidence rates.

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.

Hepatitis B virus infection and associated risk factors among medical students in eastern Ethiopia

BACKGROUND

Hepatitis B virus (HBV) is a highly contagious pathogen that has become a severe public health problem and a major cause of morbidity and mortality, particularly in developing countries. Medical students are at high occupational risk during their training. However, no facility-based studies were found among medical students in eastern Ethiopia. Thus, this study aimed to investigate the seroprevalence of Hepatitis B Virus and associated factors among medical students in eastern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among 407 randomly selected medical students from March to June 2018. A pretested and structured questionnaire was used to collect data on socio-demographic characteristics and other risk factors. A 5ml blood was collected, and the serum was analyzed for Hepatitis B surface antigen (HBsAg) using the Instant Hepatitis B surface antigen kit. Data were entered using Epidata version 3.1 and analyzed using SPSS statistical packages version 22. Outcome and explanatory variables were described using descriptive summary measures. Binary and multivariable logistic regression was conducted at 95% CI and an association at P-value < 0.05 was declared statistically significant.

RESULTS

The seroprevalence of hepatitis B virus surface antigen was 11.5% (95%CI = 8.6, 14.7). Poor knowledge of universal precaution guideline (AOR = 2.58; 95% CI = [1.35-4.93]), history of needle stick injury (AOR = 2.11; 95% CI = [1.07-4.18]) and never been vaccinated for HBV (AOR = 2.34; 95% CI = [1.17-4.69]) were found statistically significantly associated with HBsAg positivity after multivariate analysis.

CONCLUSION

Hepatitis B virus infection rate is high among health care trainees in eastern Ethiopia. Improvement at health care practice centers safety through training on universal precaution guidelines, and scaling up HBV vaccination is mandatory.

Microbiology in minimally invasive autopsy: best techniques to detect infection. ESGFOR (ESCMID study group of forensic and post-mortem microbiology) guidelines

This manuscript aims to: 1) provide specific guidelines on PMM techniques in the setting of minimally invasive autopsy (MIA), both for pathologists collecting samples and for microbiologists advising pathologists and interpreting the results and 2) introduce standardization in PMM sampling at MIA. Post-mortem microbiology (PMM) is crucial to identify the causative organism in deaths due to infection. MIA including the use of post-mortem (PM) computed tomography (CT) and PM magnetic resonance imaging (MRI), is increasingly carried out as a complement or replacement for the traditional PM. In this setting, mirroring the traditional autopsy, PMM aims to: detect infectious organisms causing sudden unexpected deaths; confirm clinically suspected but unproven infection; evaluate the efficacy of antimicrobial therapy; identify emergent pathogens; and recognize medical diagnostic errors. Meaningful interpretation of PMM results requires careful evaluation in the context of the clinical history, macroscopic and microscopic findings. These guidelines were developed by a multidisciplinary team with experts in various fields of microbiology and pathology on behalf of the ESGFOR (ESCMID – European Society of Clinical Microbiology and Infectious Diseases - Study Group of Forensic and Post-mortem Microbiology, in collaboration with the ESP -European Society of Pathology-) based on a literature search and the author’s expertise. Microbiological sampling methods for MIA are presented for various scenarios: adults, children, developed and developing countries. Concordance between MIA and conventional invasive autopsy is substantial for children and adults and moderate for neonates and maternal deaths. Networking and closer collaboration among microbiologists and pathologists is vital to maximize the yield of PMM in MIA.

Is secondary chemical exposure of hospital personnel of clinical importance?

INTRODUCTION

There is increasing concern among hospital personnel about potential secondary exposure when treating chemically contaminated patients.

OBJECTIVE

To assess which circumstances and chemicals require the use of Level C Personal Protective Equipment (chemical splash suit and air-purifying respirator), to prevent secondary contamination of hospital personnel treating a chemically contaminated patient.

METHODS

The US National Library of Medicine PubMed database was searched for the years 1985 to 2020 utilizing combinations of relevant search terms. This yielded 557 papers which were reviewed by title and abstract. After excluding papers on biological or radiological agents, or those not related to hospital personnel, 38 papers on chemicals remained. After a full-text review, 13 papers without an in-depth discussion on the risk for secondary contamination were omitted, leaving 25 papers for review. The references of these papers were searched and this yielded another seven additional citations, bringing the total to 32 papers.

INCIDENCE OF SECONDARY TOXICITY

Secondary toxicity in hospital personnel is rare: a large-scale inventory of 120,000 chemical incidents identified only nine cases, an occurrence of 0.0075%.

SKIN CONTACT AS A SECONDARY EXPOSURE ROUTE

Skin exposure is rare under normal hygienic working conditions, reflected by the very small number of cases reported in the literature: two cases with corrosive effects due to unprotected contact and one case of presumed skin absorption.

INHALATION AS A SECONDARY EXPOSURE ROUTE

Most case reports described secondary toxicity as a result of inhalation. The chemicals involved were irritating solid particles (capsaicin spray/CS), toxic gases formed in the stomach of patients (arsine/hydrazoic acid/phosphine) and vapours from volatile liquids (solvents).

FEATURES OF SECONDARY TOXICITY

Reported symptoms after secondary inhalation were generally mild and reversible (mostly irritation of eyes and respiratory tract, nausea, headache, dizziness/light-headedness) and did not require treatment. In many cases, special circumstances increased exposure: treatment/decontamination of multiple patients, regurgitation of the chemical agent from the stomach, or inadequate room ventilation.

USE OF MORE THAN STANDARD PERSONAL PROTECTIVE EQUIPMENT

Normal hygienic precautions prevent direct skin contact from exposure to common chemical agents. When solid particle contamination is extensive, a mask and eye protection should be applied. Splash proof outer clothing (splash suit) and eye protection is preferred if (partial) wet decontamination is performed on single patients. Adequate ventilation, careful removal of clothing in case of solid particles contamination and adequate disposal of gastric content reduces exposure. Hospital staff can be rotated if symptoms occur, which can be odour-mediated. The use of more elaborate personal protective equipment with an air-purifying respirator (Level C) is only necessary in exceptional cases of contamination with highly toxic volatile chemicals (e.g., sarin). It should also be considered when decontaminating a large number of patients.

CONCLUSIONS

The risk of secondary contamination and subsequent toxicity in hospital personnel decontaminating or treating chemically contaminated patients is small. Normal hygienic precautions (gloves and water-resistant gown) will adequately protect hospital staff when treating the majority of chemically contaminated patients. More extensive protection is only necessary infrequently and there is no reason to delay critical care, even if more elaborate protection is not immediately available.

Tuberculosis among prisoners & health care workers

TB in prisons and among HCW is a major public health concern in countries having high burden of disease. Prompt detection of TB is must in prisons by screening on entry, passive screening, mass screening and contact screening via clinical evaluation, smear microscopy and chest X-rays. The new rapid diagnostic methods - True-NAAT, CBNAAT and Line Probe Assay are important tools in the diagnosis. Implementation of effective preventive measures at every steps in various settings, along with airborne infection control and protective measures for staff must be ensured.

Postmortem Swabs in the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic: Report on 12 Complete Clinical Autopsy Cases

CONTEXT.—

Clinical autopsies have historically provided a fundamental contribution in the definition of the clinicopathologic basis of infectious diseases. Even though we are witnessing the decline of the clinical autopsy, its importance remains unchanged as it is the most exhaustive way to investigate diseases. The identification of the virus in postmortem tissues is a fundamental step in the definition of its clinical features.

OBJECTIVE.—

To investigate the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in postmortem examination with swabs.

DESIGN.—

We performed postmortem swabs in 12 autopsy cases of patients with a clinical diagnosis of SARS-CoV-2-related pneumonia. Our protocol consisted of a rhinopharyngeal and a tracheal swab in order to search for the virus in the upper airways, and of 2 swabs on the parenchyma of each lung. We also performed a fifth swab on the parenchyma of both lungs in order to search for other viruses that could evolve in a clinical picture of interstitial pneumonia.

RESULTS.—

Overall, we found 9 of 12 cases had at least 1 postmortem swab positive for SARS-CoV-2. Moreover, we evaluated the time between the antemortem and postmortem swabs, the time between death and the postmortem swabs, and the time between the postmortem swabs and acceptance to the microbiology laboratory. Of note, we did not find a relationship between the results of the swabs and either the time elapsed from their collection or the time elapsed before their acceptance in the microbiology laboratory.

CONCLUSIONS.—

A thorough knowledge of the eventual persistence of pathogens in deaths related to infectious diseases is fundamental for the safety of the operators during the autopsy practice, especially when referring to emergent pathogens, such as SARS-CoV-2. Our study highlights the importance in performing multiple swabs in the postmortem examination, because SARS-CoV-2 swab positivity can be limited to only a single swab.

Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic

CONTEXT.—

The novel coronavirus disease 2019 (COVID-19) pandemic is significantly changing methodologic approaches in all branches of the health system. From a forensic point of view, this event is partly changing the manner in which forensic pathologists and all those who work in autopsy services operate, but above all, it is changing the patterns established for years by which cadavers are analyzed postmortem.

OBJECTIVE.—

To present a review of the literature and a proposal for COVID-19 autopsy protocols. To contain the infection risk, a revision of all the protocols that until now have been applied to the examination of bodies that require autopsy services is required.

DATA SOURCES.—

Currently, the diagnosis and postmortem analysis of positive or suspected COVID-19 cases plays a crucial role in scientific research. A review of the main recommendations proposed by international scientific societies regarding the risk of infection during autopsy was carried out. Scientific papers currently available via the PubMed NCBI search engine on COVID-19 postmortem diagnosis were also examined.

CONCLUSIONS.—

Throughout the history of medicine, autopsy has been fundamental to the understanding of multiple pathogenic processes that are investigated postmortem. The purpose of the study is to propose an operating protocol that can be useful for all clinical and forensic autopsies, with particular reference to the correct methods to be applied to the examination of positive or suspected COVID-19 cases, regarding both the autopsy procedure and the collection and analysis of biological samples.

Autopsy Identification of Viable Mycobacterium Tuberculosis in the Lungs of a Markedly Decomposed Body

Various infectious diseases, including COVID-19, MERS, and tuberculosis, are global public health issues. Tuberculosis, which is caused by Mycobacterium tuberculosis (MTB), is highly contagious and can be transmitted through inhalation of the bacteria. However, it has been assumed that the infectiousness of bacteria and viruses in dead bodies weakens as the time from death increases. In particular, there is little awareness of infection control measures concerning decomposed bodies or even the need for such measures. The deceased, in whom we discovered MTB 3 months following her death, was a woman in her 80s who died at home. We performed judicial autopsy, because police suspected homicide when her husband hanged himself. Obtained organs were used for microscopic examination by hematoxylin-eosin staining and Ziehl-Neelsen staining. In addition, real-time PCR and mycobacterial culture testing using Ogawa's medium were performed for the detection of MTB. We found that the MTB in the decomposed body remained viable and potentially infectious. To identify the bacterial strain further, we performed DNA-DNA hybridization and identified the strain as MTB complex. Potentially infectious live MTB survived in the dead body far longer than had been previously reported. Pathologists should consider microbial culture tests for all autopsied cases in which the decedent's medical history or macro-examination suggests possible infection, even when a long duration of time has passed since death. Pathologists and specialists who perform autopsies should recognize that all dead bodies are potentially infectious, including those in which long periods have elapsed since death.

No-Touch Automated Room Disinfection after Autopsies of Exhumed Corpses

Autopsies of exhumed bodies pose a risk of infections with environmental bacteria or fungi, which may be life-threatening. Thus, it is important to use effective methods of disinfection in forensic pathology facilities. In this study, we investigated the effectiveness of no-touch automated disinfection (NTD) system after autopsies of exhumed bodies. Directly after 11 autopsies of exhumed bodies, we used an NTD system based on a peroxone vapor to disinfect the air and surfaces. We measured microbial burden in the air and on surfaces before and after NTD. The NTD system reduced the mean bacterial burden in the air from 171 colony forming units (CFU)/m³ to 3CFU/m³. The mean fungal burden in the air decreased from 221 CFU/m³ to 9CFU/m³. The mean all-surface microbial burden was 79 CFU/100 cm² after all autopsies, and it decreased to 2 CFU/100 cm² after NTD. In conclusion, the peroxone-based NTD system was effective for decontamination of the air and surfaces in a dissecting room after autopsies of exhumed bodies.

Sharps Injuries during Dissection: A Five-Year Retrospective Study in the Context of Safety

The supplementation of lecture-based anatomy teaching with laboratory sessions, involving dissection or anatomical specimens, is commonly used. Hands-on dissection allows students to handle instruments correctly while actively exploring three-dimensional anatomy. However, dissection carries a potential risk of sharps and splash injuries. The aim of this study was to quantify the frequency rate of such cases per 1,000 student-hours of dissection and identify potential factors than might influence safety in anatomy laboratories. Data were retrospectively collected from September 2013 to June 2018 at the University of St Andrews, Scotland, UK. Overall, 35 sharps injuries were recorded in undergraduate medical students, with a frequency rate of 0.384 and no splash cases. A statistically significant, moderate negative association between year of study and frequency rate (rho₍₂₅₎ = -0.663; P < 0.001) was noted. A statistically significant difference in the frequency rate between different semester modules (χ² ₍₄₎ = 13.577, P = 0.009) was observed with the difference being between Year 1 Semester 2 and Year 3 Semester 1 (P = 0.004). The decreasing trend with advancing year of study might be linked to increasing dissecting experience or the surface area of the region dissected. The following factors might have contributed to increased safety influencing frequency rates: single-handed blade removal systems; mandatory personal protective equipment; and having only one student dissecting at a given time. The authors propose that safety familiarization alongside standardized training and safety measures, as part of an evidence-based culture shift, will instill safety conscious behaviors and reduce injuries in anatomy laboratories.

Biosafety in autopsy room: an systematic review

Objective To discuss the risks related to the possibilities of accidents and contamination in autopsy rooms, especially the biological risk.Methods This is an exploratory study. The databases Lilacs, MEDLINE and SciELO virtual library were searched; from 2000 until 2017; from the following inclusion criteria: articles available in full, in Portuguese, English and Spanish languages; and those that portrayed the central theme of the article.Results 53 articles were analyzed, to following the sub-themes: chemical, ergonomic, biological and accident agents; exposure to radioactive materials; electrical and electronic equipment.Conclusions The death cause is essential for epidemiological surveillance. The prevalence of diseases in the population poses risk to autopsy room professionals. Often these diseases are not detected before death; can coexist with other conditions and be ignored; or don’t have morphological evidence at autopsy. M.tuberculosis, hepatitis virus, HIV and prions were the main pathogens identified. They can be transmitted by blood and aerosols; but there are other risks such as sharps, chemicals and radioactive materials.

An atlas overview of characteristic features of tuberculosis that may be encountered at autopsy

Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis. Although primarily a disease of the respiratory system it may be found in any organ or tissue. Global population movements and the emergence of resistant strains are contributing to increasing numbers of cases in certain populations. Subtlety of symptoms and signs, chronicity of disease and failure to seek medical assistance may result in the diagnosis only being made at the time of autopsy. For this reason forensic pathologists need to understand the protean manifestations of the disease and the variable mechanisms by which TB may cause death. This atlas overview provides descriptions of the pathological manifestations of TB in a variety of organs with accompanying illustrations. It serves as a summary of conditions that should be checked for at autopsy in suspected or confirmed cases.

Minimizing aerosol bone dust during autopsies

When sawing bone for medical or medico-legal procedures, fine, airborne dust is produced (aerosols) that can pose a health hazard when inhaled. The aim of this study was to determine the influence of saw blade frequency and contact load, bone condition, test environment, and saw blade type, on the production of aerosol particles. A custom test setup was designed, manufactured and used in 8 bone sawing experiments, using a particle counter to determine the production of aerosol particles while varying the 5 chosen parameters. The number of counted particles was highest with higher saw blade frequencies, lower saw blade contact loads, in dry completely skeletonized bone compared to fresh bone, and using an electrical oscillating saw compared to hand-sawing. Under all conditions, the high amount of aerosol counted posed potential health risks. The ventilation system that we tested was adequate in removing the produced particles, but these high-tech systems are not always available in developing countries or emergency situations. The production of aerosols can be reduced by optimizing the sawing parameters. However, even the lowest number of aerosol particles counted during the current study was high enough to cause potential health risks to practitioners. Safety precautions should be taken, such as external ventilation, proper breathing gear, and adequate protocols, to truly minimize the risk in all bone sawing scenarios.

Perforation rates in double latex gloves and protective effects of outer work gloves in a postmortem examination room: A STROBE-compliant study

Medical staff face the risk of exposure to blood-borne infectious agents during postmortem examinations. This study investigated the effectiveness of non-slip work gloves worn over 2 layers of surgical latex gloves (outer and inner gloves) as a means of reducing hand and finger injuries. Complete sets of outer and inner gloves worn during postmortem examinations were collected from participating forensic staff. Latex gloves were categorized into 2 groups based on the users' actions during the examination: the wearing group if the wearer wore their work gloves continuously without interruption, and the taking-off group if the wearer removed them at least once. Perforation rates, locations, and shapes were compared between these groups. Outer-glove perforation occurred significantly more often in the taking-off group (n = 102 pairs) than in the wearing group (n = 91 pairs) (30.4% vs 3.8%, P < .001). Inner-glove perforation occurred at rates of 2.0% and 0.5% (P = .38), respectively. The wearers did not incur hand or finger injuries. Perforation rates were similar between the dominant and non-dominant hands (P = .18). Regarding location, gloves were punctured most frequently at the thumb, followed by the index finger. Most examiners (85.6%) did not notice the perforation when the damage occurred. Therefore, we could not confirm that a specific operation within a set of plural operations affected the rate of perforation. Additionally, we could not prove a relationship between glove perforation and each operation performed with/without work gloves. The perforation appearances varied greatly in shape and size, suggesting multiple causes of perforation. The continuous (i.e., uninterrupted) wear of work gloves during postmortem examinations reduced the incidence of perforations in both latex glove layers and thus reduced the risk of hand and finger injury.

Tuberculosis-related stigma contributing to a 'hidden' disease at autopsy

A 29-year-old African immigrant to Australia was found dead in bed. She had no known medical history, except for recent weight loss and hip/leg pain. Autopsy examination revealed extensive tuberculous consolidation with widespread cavitation of the lungs, with multiple caseating granulomas containing large numbers of acid fast bacilli on histology. Similar granulomas were also present in lymph nodes of the porta hepatis, mediastinum and pulmonary hilum, and within the liver, spleen and mesentery. Mycobacterial polymerase chain reaction analysis confirmed tuberculous infection. Her serum was negative for human immunodeficiency virus infection. Death was due to disseminated tuberculosis. In many parts of Africa, there are negative cultural associations attached to tuberculosis, which often leads to a delay in diagnosis. The case demonstrates the extent of active disease that may be uncovered at autopsy in decedents from societies where tuberculosis is stigmatised and therefore concealed. It also emphasises the risk of infection for forensic workers.

Issues in the handling of cases of tuberculosis in the mortuary

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (MTB) that is most often transmitted by the inhalation of bacteria-containing aerosols. While there has been a decline in numbers of cases in certain countries, large population movements, the increasing emergence of drug-resistant strains and the association with human immunodeficiency virus (HIV) infection make it a disease that is increasingly seen in forensic practice. Mortuary staff are at risk of infection from penetrating sharp injuries, droplet inhalation, ingestion, direct inoculation, through skin breaks or through mucous membranes of the eyes, nose and mouth. While the health and safety measures outlined by agencies may vary slightly, the principles of handling infectious autopsy cases remain the same with awareness and education, immunisation and regular tuberculin testing of staff, pre-necropsy screening of decedents, use of personal protective equipment, and the implementation of safe sharps practices and measures to reduce aerosol formation.

[The conditions and the character of the work of the mortuary personnel in the Great Britain: the problems of health protection, anti-infectious prophylaxis, and reduction of the risk of contamination]

The objective of the present work was to study the specific approaches to the organization of the work of the foreign specialists performing post-mortem autopsies of the subjects who died from infectious pathology and consider the proposals of the representatives of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) concerning accreditation of mortuaries in the Great Britain. It is shown that the algorithm for the evaluation of the possible risks of contamination of the medical personnel suggests the solution of five problems that envisages obtaining the answers to the following questions: (1) what biological agents can be present in a particular case? (2) what is their virulence factor? (3) what are the transmission routes (mechanisms)? (4) what are the manner of their realization? (5) what is the amount of the pathogen(s) needed to cause a given infectious disease? The anti-infectious prophylactic measures and the prevention of the contamination risks for the medical personnel of the British mortuaries are designed to safeguard the people against the infection with the causative agents of tuberculosis, viral hepatitis B and C, HIV, and Kreutsfield- Jacob's disease. All the employees engaged in the pathological studies must wear specialized clothing in a mandatory manner and make use of the equipment for the personal and collective protection. An indispensable condition for the safe work in a mortuary is the efficient ventilation system, the special viewing equipment, and separate premises. The NCEPOD experts maintain that the general approach to the investigations of the cases of infectious diseases presently adopted in the country needs to be radically re-considered and standardized. Diagnostics of contamination and morbidity of the medical personnel from the corpses has not yet become a routine practice. The principal recommendation to be implemented at the national level consists of the strict observance of the safety precautions as opposed to the total pre-mortem testing of the suspicious cases.

Postmortem microbiology sampling following death in hospital: an ESGFOR task force consensus statement

Postmortem microbiology (PMM) is a valuable tool in the identification of the cause of death and of factors contributory to death where death has been caused by infection. The value of PMM is dependent on careful autopsy planning, appropriate sampling, minimisation of postmortem bacterial translocation and avoidance of sample contamination. Interpretation of PMM results requires careful consideration in light of the clinical history, macroscopic findings and the histological appearances of the tissues. This consensus statement aims to highlight the importance of PMM in the hospital setting and to give microbiological and pathological advice on sampling in deaths occurring in hospital.

Post-mortem microbiology in sudden death: sampling protocols proposed in different clinical settings

BACKGROUND

Autopsies, including minimally invasive autopsies, are a powerful tool for determination of the cause of death. When a patient dies from an infection, microbiology is crucial to identify the causative organism. Post-mortem microbiology (PMM) aims to detect unexpected infections causing sudden deaths; confirm clinically suspected but unproven infection; evaluate the efficacy of antimicrobial therapy; identify emergent pathogens; and recognize medical errors. Additionally, the analysis of the thanatomicrobiome may help to estimate the post-mortem interval.

AIMS

The aim was to provide advice in the collection of PMM samples and to propose sampling guidelines for microbiologists advising autopsy pathologists facing different sudden death scenarios.

SOURCES

A multidisciplinary team with experts in various fields of microbiology and autopsies on behalf of the ESGFOR (ESCMID - European Society of Clinical Microbiology and Infectious Diseases - study group of forensic and post-mortem microbiology and in collaboration with the European Society of Pathology) developed this narrative review based on a literature search using MedLine and Scopus electronic databases supplemented with their own expertise.

CONTENT

These guidelines address measures to prevent sample contamination in autopsy microbiology; general PMM sampling technique; protocols for PMM sampling in different scenarios and using minimally invasive autopsy; and potential use of the evolving post-mortem microbiome to estimate the post-mortem interval.

IMPLICATIONS

Adequate sampling is paramount to identify the causative organism. Meaningful interpretation of PMM results requires careful evaluation in the context of clinical history, macroscopic and histological findings. Networking and closer collaboration among microbiologists and autopsy pathologists is vital to maximize the yield of PMM.

Aerosol production during autopsies: The risk of sawing in bone

When sawing during autopsies on human remains, fine dust is produced, which consists of particles of sizes that may fall within the human respirable range, and can act as vectors for pathogens. The goal of this study was to explore the potential effects of saw blade frequency and saw blade contact load on the number and size of airborne bone particles produced. The methodology involved the use of an oscillating saw with variable saw blade frequencies and different saw blade contact loads on dry human femora. Released airborne particles were counted per diameter by a particle counter inside a closed and controlled environment. Results corroborated with the hypotheses: higher frequencies or lower contact loads resulted in higher numbers of aerosol particles produced. However, it was found that even in the best-case scenario tested on dry bone, the number of aerosol particles produced was still high enough to provide a potential health risk to the forensic practitioners. Protective breathing gear such as respirators and biosafety protocols are recommended to be put into practice to protect forensic practitioners from acquiring pathologies, or from other biological hazards when performing autopsies.

Prevalence of HCV, HBV, and HIV Seropositivity among Cadavers Referred to Autopsy Hall of Legal Medicine Bureau of Tehran, Iran

A large number of dead bodies are referred to forensic autopsy halls for medicolegal examination. They can be a source of transmission of infectious diseases through direct contact or autopsy tools. The main aim of this study was to estimate the virus infection rates in the dead bodies. One thousand consecutive dead bodies that had been referred to autopsy hall of Legal Medicine Bureau of Tehran, Iran, during 2016, were included. The blood samples were analyzed in the laboratory for detection of HBs Ag, HBs Ab, HIV Ab, and HCV Ab, after providing informed consent from legal next of kin of the dead bodies. The general characteristics of the dead bodies were also collected by a checklist. Forty-seven cases of HIV seropositivity, 80 cases of HBs Ag seropositivity, and 97 cases for HCV Ab seropositivity were found. Among them, 27 cases of HIV, 40 cases of anti-HBC positive, and 94 cases of RIBA testing positive for HCV were proved through confirmatory tests. In other words, 2.6% of the dead bodies were infected with HIV, 3.8% with HBV, and 9% with HCV. The total infection rate was 15.5%. This is a worrying risk for pathologist and autopsy technicians.

Study of mortality from infectious diseases in Brazil from 2005 to 2010: risks involved in handling corpses

In the wake of disasters, the lack of information on how to handle and dispose of corpses leads the professionals involved in emergency operations to uncertainty about associated risks and safety precautions. The article seeks to establish the risks of the etiologic agents involved in Brazilian mortality due to infectious diseases and identify and discuss the main protection measures for professionals involved in handling of corpses in disaster situations. It involved a survey of deaths by infectious diseases in Brazil between 2005 and 2010, using data from the Mortality Information System. Of the 171,223 deaths analyzed, the pathogens leading to the greatest number of deaths were: HIV, Mycobacterium tuberculosis and Trypanosoma cruzi. 59% belonged to risk class 3 and 40.6% to risk class 2. Eight deaths were caused by risk class 4 pathogens, which represent high risk. The professionals involved in the handling of corpses may be exposed to chronic risks, such as viruses transmitted via blood, gastrointestinal infections and tuberculosis. These findings indicate the importance of investment in the preparation of measures to reduce the risk of infection associated with the handling of corpses.

Prevalence of blood-borne viral infections among autopsy cases in Jordan

Background: Morgues are high risk areas for the spread of infection from cadavers to staff during the post-mortem examination. Infection can spread from corpses to workers by airborne transmission, by direct contact, or through needle and sharp object injuries. Objective: Knowledge about the prevalence of these infections on autopsy is essential to determine the risk of transmission and to further enforce safety measures. Methods: This is a descriptive study. All autopsies performed in the Department of Forensic Medicine at Jordan University Hospital during the study period were tested for the serology of human immunodeficiency, hepatitis B and C viruses. Positive tests were confirmed by nucleic acid testing. Results: A total of 242 autopsies were tested. Age ranged from 3 days to 94 years (median 75.5 years, mean 45.3 years (21.9 ±  SD)). There were 172 (71%) males. The cause of death was considered natural in 137 (56.6%) cases, accidental in 89 (36.8%), homicide in nine (3.7%), suicide in four (1.7%), and unknown in three (1.2%) cases. Hepatitis B surface antigen was positive in five (2.1%) cases. Hepatitis C virus antibody was positive in five (2.1%) cases and the hepatitis C virus polymerase chain reaction was positive in two (0.8%) cases. HIV antibody was not detected in any of the cases. The infection status of cases was not associated with age, sex, nationality, or cause of death. Conclusion: The study findings indicated that there is a low prevalence of virus-infected autopsies in Jordan. However, the risk of transmission remains a potential threat and therefore the necessary precautions should always be taken during autopsy.

FORENSIC RADIOLOGY AND IMAGING FOR VETERINARY RADIOLOGISTS

Imaging studies are often of evidentiary value in medicolegal investigations involving animals and the role of the veterinary radiologist is to interpret those images for courts as an expert or opinion witness. With progressing interest in prosecuting animal crimes and strengthening of penalties for crimes against animals, the participation of veterinary radiologists in medicolegal investigations is expected to increase. Veterinary radiologists who are aware of radiographic and imaging signs that result in animal suffering, abuse, or neglect; knowledgeable in ways radiology and imaging may support cause of death determinations; conversant in postmortem imaging; comfortable discussing mechanisms and timing of blunt or sharp force and projectile trauma in imaging; and prepared to identify mimics of abuse can assist court participants in understanding imaging evidence. The goal of this commentary review is to familiarize veterinary radiologists with the forensic radiology and imaging literature and with the advantages and disadvantages of various imaging modalities utilized in forensic investigations. Another goal is to provide background information for future research studies in veterinary forensic radiology and imaging.

An Autopsy Checklist: A Monitor of Safety and Risk Management

Any autopsy has safety and risk management issues, which can arise in the preautopsy, autopsy, and postautopsy phases. The London Health Sciences Department of Pathology and Laboratory Medicine Autopsy Checklist was developed to address these issues. The current study assessed 1 measure of autopsy safety: the effectiveness of the checklist in documenting pathologists' communication of the actual or potential risk of blood-borne infections to support staff. Autopsy checklists for cases done in 2012 and 2013 were reviewed. The frequency of communication, as recorded in checklists, by pathologists to staff of previously diagnosed blood-borne infections (hepatitis B/C and human immunodeficiency virus) or the risk of infection based on lifestyle (eg, intravenous drug abuse) was tabulated. These data were compared with medical histories of the deceased and circumstances of their deaths described in the final autopsy reports. Information about blood-borne infections was recorded less frequently in the checklists compared with the final reports. Of 4 known human immunodeficiency virus cases, there was no checklist documentation in 3. All 11 hand injuries were documented. None of these cases had known infectious risks. The Autopsy Checklist is a standardized means of documenting safety and risk issues arising during the autopsy process, but its effectiveness relies on accurate completion.

Aerosol Generation During Bone-Sawing Procedures in Veterinary Autopsies

Bone-sawing procedures are routinely performed during veterinary and human autopsies and represent an important source for infectious aerosols. Here we investigate the generation of aerosols during bone-sawing procedures using 5 different saws regularly used in veterinary and human pathology. In particular, the electrical bone band saw produced vast amounts of aerosolized particles less than 5 µm in diameter, which spread rapidly throughout the entire autopsy hall, leading to an exposure of all personnel. Other sawing devices tested were a diamond-coated cut grinder, an oscillating saw, a reciprocating saw, and a hand bone saw. Although these saws, especially the handsaw, generated fewer aerosolized particles than the band saw, the level of exposure of the saw operator would still be of concern in cases where infectious material would require sawing. Contamination of the entire autopsy area was successfully prevented by the construction of a separately ventilated sawing cabin inside the existing autopsy room. Saw operators in this cabin, however, were exposed to even higher aerosol concentrations. Protection of saw operators was achieved by using a powered air-purifying respirator. In conclusion, our results demonstrate that all bone-sawing procedures applied in veterinary and human pathology can generate aerosols that are of concern for the health of autopsy personnel. To reduce the risk of aerosol infections from bone-sawing procedures, efficient and properly designed ventilation systems to limit the spread of aerosols and appropriate personal protective equipment against aerosols for exposed personnel should be implemented.

An Update on the Hazards and Risks of Forensic Anthropology, Part II: Field and Laboratory Considerations

This paper focuses on potential hazards and risks to forensic anthropologists while working in the field and laboratory in North America. Much has changed since Galloway and Snodgrass published their seminal article addressing these issues. The increased number of forensic practitioners combined with new information about potential hazards calls for an updated review of these pathogens and chemicals. Discussion of pathogen hazards (Brucella, Borrelia burgdorferi, Yersinia pestis, Clostridium tetani and West Nile virus) includes important history, exposure routes, environmental survivability, early symptoms, treatments with corresponding morbidity and mortality rates, and decontamination measures. Additionally, data pertaining to the use of formaldehyde in the laboratory environment have resulted in updated safety regulations, and these are highlighted. These data should inform field and laboratory protocols. The hazards of working directly with human remains are discussed in a companion article, "An Update on the Hazards and Risks of Forensic Anthropology, Part I: Human Remains."

Infection Management and Health Practices Among Forensic Science Investigators in South Korea

This study investigated the current status of infection management for forensic science investigators in South Korea. This study included 104 forensic science investigators, of which 97.1% were exposed to the blood or body fluids of corpses during handling. Of these investigators, 98% claimed they wore gloves, and 12.9% used double-layered gloves. A total of 70.6% of the participants with relevant work experience wore masks to reduce infection risk; 43% wore gowns and goggles when at risk of contracting an infection. Furthermore, 59.8% of the investigators with pertinent work experience sought appropriate first aid and treatment when they experienced contaminated skin cuts or stab wounds. Working conditions and other problems should be analyzed consistently with the cooperation of employees, occupational health practitioners, and relevant organizations to prevent work-associated infections among forensic science investigators.

Occupational health risks of pathologists--results from a nationwide online questionnaire in Switzerland

BACKGROUND

Pathologists are highly trained medical professionals who play an essential part in the diagnosis and therapy planning of malignancies and inflammatory diseases. Their work is associated with potential health hazards including injuries involving infectious human tissue, chemicals which are assumed to be carcinogenic or long periods of microscope and computer work. This study aimed to provide the first comprehensive assessment of the health situation of pathologists in Switzerland.

METHODS

Pathologists in Switzerland were contacted via the Swiss Society of Pathologists and asked to answer an ethically approved, online anonymous questionnaire comprising 48 questions on occupational health problems, workplace characteristics and health behaviour.

RESULTS

163 pathologists participated in the study. Forty percent of pathologists reported musculoskeletal problems in the previous month. The overall prevalence was 76%. Almost 90% of pathologists had visual refraction errors, mainly myopia. 83% of pathologists had experienced occupational injuries, mostly cutting injuries, in their professional career; more than one fifth of participants reported cutting injuries in the last year. However, long lasting injuries and infectious diseases were rare. Depression and burnout affected every eighth pathologist. The prevalence of smoking was substantially below that of the general Swiss population.

CONCLUSIONS

The results of this study suggest that more care should be taken in technical and personal protective measures, ergonomic workplace optimisation and reduction of work overload and work inefficiencies. Despite the described health risks, Swiss pathologists were optimistic about their future and their working situation. The high rate of ametropia and psychological problems warrants further study.