As sudden unexpected deaths fall under Medical Examiner/Coroner jurisdiction, they may play a fundamental role in the response to infectious disease deaths. If communication between various health sectors is unclear or protocols have not been established by the local health department, there is a risk for occupational exposure for all parties involved, and the potential for a ME/C to be exposed to a highly infectious death that has yet to be confirmed. The logistical challenges associated with the response to highly infectious pathogens is demanding for public health sectors focused on the treatment and management of living patients. The role of the death care sector in effective disease surveillance and containment of infectious diseases is often overlooked; including the fundamental role of ME/Cs. ME/Cs frequently investigate deaths with little clinical information on the circumstances preceding death. Hence, it is crucial to for ME/Cs to have robust, up-to-date education and training in potential highly infectious remains handling, PPE donning and doffing, and clear protocols used when handling human remains that stress universal precautions. To determine what training areas are insufficient or need to be supplemented, this survey evaluated current ME/C office capability to handle highly infectious remains.
This survey provided a national view of the handling of highly infectious remains by capturing a sample of ME/Cs from nearly every state and Washington D.C. Medical examiners comprised the majority of the survey respondents and were more evenly geographically distributed than coroners. Nearly half of the respondents served large counties or metropolitan areas with populations of greater than one million people, highlighting the large populations that may be covered by a single ME/C office. Additionally, most ME/C offices, including the body storage areas (morgues), are under government oversight.
In order to gauge circumstance-dependent PPE use among ME/Cs, respondents were asked for standard PPE ensembles worn during routine autopsies and those worn for autopsies on suspected or confirmed highly infectious remains (Table 1). Slightly more than half (52%) reported wearing an N95 respirator during routine autopsies and this increased to only 68% for autopsies on suspected or confirmed highly infectious remains. Other higher level PPE such as a powered-air purifying respirator (increased by over 30%), Tyvek suit, HAZWOPER gear and SCBA also showed an increase. A surgical mask was worn by 35% in standard autopsies and by 6% of ME/Cs for a suspected or confirmed highly infectious case. Typically, at minimum an N95 is recommended for protection against aerosolized particles arising such as TB, Monkeypox, SARS and others, rather than a surgical mask . Additionally, an autopsy is inherently an aerosol-generating procedure, even organisms that might normally require only large droplet precautions (i.e. surgical mask) can be aerosolized at autopsy due to oscillating saws, aspirating hoses, etc. and thus require added respiratory precautions (i.e. N95 respirator or PAPR) [33, 38, 39]. Use of a face shield rather than glasses/goggles also has been shown to reduce contamination of respirators by particles but only 59% of ME/C respondents routinely wear them .
The following PPE changes occurred for suspected or highly infectious remains: the use of inner gloves, a face shield, and boot/shoe cover wear increased by 6%, 17%, and 7%, respectively, while donning eye protection decreased by 4%. Usage of a N95 respirator increased by more than 15% and the use of a powered-air purifying respirator notably increased by nearly 30%. Higher level PPE, such as a Tyvek suit, HAZWOPER gear and SCBA also were used when autopsies were performed on suspected or confirmed highly infectious remains. Of concern, these results indicate ME/C alter their PPE based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach. Despite some improvements in more protective ensembles in the suspected increased risk cases, the amount of training received by respondents was lacking. Little more than half (56%) of respondents had received training on donning and doffing PPE in such scenarios, with the 61% of those who did have PPE training having spent an average of only 2 h or less per person per year on the topic.
Additionally, the entity that provided PPE training widely varied (e.g. in-house staff, affiliated university, safety and compliance departments), and no information was collected on the survey on the expertise level of those delivering trainings. The lack of reproducible training time and variability of training entity suggest that more standardized training might be of benefit. Designating a knowledgeable public organization to offer standardized training modules could lead to the following: (1) standardization of the organizational source of training; (2) content of training materials and modules based on reproducible, evidence-based best practices commonly found in the ME/C field; and (3) subscription to online training as it will likely be the most cost-effective and convenient means of training, as was proven successful in healthcare . Moreover, best practices and evidence-based studies have demonstrated that regular training for donning and doffing high level PPE in highly infectious scenarios provide substantially better occupational safety and health outcomes for the employee .
In the event of suspected or confirmed highly infectious remains, most ME/C offices stated that the situation was handled on a case-by-case basis, depending on the pathogen that was suspected and required detailed conversations with all stakeholders. As shown in Table 2, procedures did vary between what would be performed with a suspected highly infectious body versus a confirmed infectious body. In a confirmed case, all but one of the listed procedures as decreased compared to a suspected case (e.g. complete autopsy [27% decrease], washing or cleaning of the body [17% decrease], body storage in freezer [20% decrease]). The only increase was, “bypass office and have body directly transported to funeral home/crematorium” by 21% which, as previously mentioned, may result in funeral home and crematory personnel being placed at risk.
Fewer than 50% of ME/C offices having been involved with handling a suspected or confirmed case, demonstrating a lack experience in handling highly infectious remains. When asked which suspected or confirmed pathogens were encountered, however, many noted Category A or B pathogens (Table 4) [1, 2] that require specific deactivation and decontamination procedures—of which only approximately one-third (38%) of respondents had received training in. It is possible that after such an event that the ME/C office would hire an appropriate contractor to conduct the appropriate deactivation and decontamination; however, the possibility remains that the task could go to individuals within the ME/C offices without proper training.
While most offices did not have a BSL-3 facility, nearly two-thirds (60%) of those without a BSL-3 did have BSL-2 capabilities. However, if 40% have only BSL-1 capability, then these morgues would essentially be considered appropriate for work only with agents not known to consistently cause disease in healthy human adults per CDC guidelines . In essence, a sizeable percentage of morgues in the U.S. are not equipped to safely perform autopsies on human remains with a large number of infections, especially those highly infectious disease autopsies. In addition to improved training, more investment in morgue infrastructure would be necessary to enhance their capabilities. Anecdotally, some larger ME/C offices have a computerized tomography (CT) scanner in which triple bagged sealed infectious remains can undergo virtual autopsy. These bags can be constructed with portals to collect needed specimens for microbiologic/virologic studies. The triple bagging prevents leaks and contamination and the remains can safely be sent to funeral home. It would also be beneficial to have list of pathologists and support personnel in each ME/C office who could volunteer to take vaccines to handle certain cases with suspected contagious diseases (i.e. smallpox, etc.).
Approximately 20% of respondents reported that they did not examine suspected or confirmed highly infectious remains at their facility. Given the lack of proper BSL facilities, this would be appropriate. Slightly more than 20% noted the lack of space and/or a lack of staff in their offices as a limitation for being able to perform autopsies of suspected or confirmed highly infectious remains in a separate room or alone. For biosafety, it is recommended that autopsy facilities should have a minimum of 12 air exchanges per hour, be negatively pressurized relative to surrounding office spaces, and exhaust air outside of the facility and away from areas of high pedestrian traffic. Morgue laminar air flow should travel from clean to progressively less clean areas with downdraft table ventilation to decrease personnel exposure to aerosolized pathogens [32, 39]. It is likely that significant financial investment would be required to retrofit many existing morgues to meet these standards. Another option would be to have jurisdictional planning to transport suspected or confirmed cases to known centers that currently have the necessary BSL capability; again, body transportation would incur costs but likely lower costs than that associated with retrofitting many existing morgues. In addition to improved morgue biosafety, it would also benefit ME/C facilities to have better publicized, easily accessed, and clearly laid-out protocols for various infectious scenarios in which limited autopsy (e.g. brain-only in suspected CJD cases) or no autopsy (e.g. EVD cases) is currently recommended.
When asked about level of training to handle and transport specimens for suspected highly infectious cases, only one-third of respondents had received this training with 20% spending on average less than 1 h per year per person on the topic. Nearly half of respondents (47%) were unsure of what their jurisdiction permitted in the case of highly infectious remains for ultimate disposal, and alarmingly, 13% of respondents stated their jurisdiction permitted embalming and 15% traditional burial. For EVD, for example, the recommended procedure is cremation to ensure complete deactivation of the virus in order to prevent spread to workers and the environment; those who were killed by the disease will have high viral loads present in their body post-mortem . While needs for funding, resources, supplies and appropriate capabilities may be universal across the death care sector, this survey’s results strongly suggest that it would benefit state or regional-specific ME/Cs to have standardized education and training throughout the U.S . Likewise, open-ended comments from respondents indicated a need for augmented up-to-date formalized trainings, as well as revised written policies and procedures, and enhanced resources (including facilities and funding). There were general perceptions of unpreparedness to address highly infectious remains, budgetary constraints and a weak national structure regarding autopsy biosafety, and a lack of incorporation of ME/C offices into infection control planning despite ME/C office involvement with highly infectious remains.
There were limitations to this study. Because of the study’s exploratory nature, the survey was not validated beyond subject matter expert vetting. Additionally, the survey only included ME/C offices that served larger populations; smaller offices may still encounter HID cases if they do not outsource larger nearby offices. Therefore, this study may not be generalizable to smaller offices (i.e. those serving populations <300,000). Also, the survey instrument was designed to allow respondents to check multiple boxes when asked about the use of PPE. The results, therefore, were not clear whether the respondent meant the PPE would be used simultaneously or one instead of the other. For example, a face shield and respirator may be used simultaneously or a face shield may be used instead of a respirator. Additionally, a limitation related to potential response bias may exist. Although this study was not funded, there could have been sponsor bias on behalf of the respondents, as the survey was distributed by members of NAME, thereby potentially affecting the candidness of their responses. Lastly, non-responses may have arisen because it would not appeal to prospective participants to take a survey about a topic for which they are not trained out of concern their answers may not be “correct.” Nevertheless, this study addresses a critical gap about what is known and unknown about U.S. ME/C capabilities to handle highly infectious remains.
In conclusion, this survey of U.S. medical examiners and coroners’ capabilities to address highly infectious decedents presents opportunities for improvement at ME/C facilities serving their state or metropolitan area. Standard operating procedures or guidelines (SOPs or SOGs) should be updated to take an all-hazards approach, best-practices on handling highly infectious remains could be integrated into a standardized education, evidence-based information on appropriate PPE selection could be integrated into a widely disseminated learning module, and existing relationships with the local health department, funeral homes and crematories could be bolstered to develop a multi-sectoral concept of operations for addressing suspected highly infectious remains. While some issues will require greater capital and resources to address—such as retrofitting facilities to meet better biosafety recommendations, or more financial resources to enhance operation—the hope is that this study will draw attention to these more systemic issues and stimulate a call to action from the appropriate entities.