by
Briefing on COVID-19
Autopsy practice relating to possible
cases of COVID-19 (2019-nCov, novel
coronavirus from China 2019/2020)
This briefing is for mortuary staff who are potentially exposed to material including body
fluids from the deceased in the mortuary.
Authors: Dr Michael Osborn, Imperial College Healthcare NHS Trust
Professor Sebastian Lucas, Guy’s and St Thomas’ NHS Foundation Trust
Ruby Stewart, Guy’s and St Thomas’ NHS Foundation Trust
Dr Ben Swift, Home office Forensic Pathologist, Forensic Pathology Services.
Dr Esther Youd, Cwm Taf Morgannwg Health Board
The Royal College of Pathologists
6 Alie Street
London E1 8QT
T: 020 7451 6700
F: 020 7451 6701
www.rcpath.org
Registered charity in England and Wales, no. 261035
© 2020 The Royal College of Pathologists
You may download, display, print and reproduce this document for your personal, non-commercial use. All other rights
are reserved. Requests and inquiries concerning reproduction and rights should be addressed to the Royal College of
Pathologists at the above address.
Pub February 2020 2 V1 Final
Contents
Contents………………………………………………………………………………………………………………………. 2
1. Introduction………………………………………………………………………………………………………………. 3
1.1 Categorisation of infectious hazard ………………………………………………………………………………. 3
1.2 HG definition: COVID-19…………………………………………………………………………………………….. 3
1.3 Scope of these guidelines…………………………………………………………………………………………… 4
1.4 Target users and health benefits of these guidelines ………………………………………………………. 5
2. Pathology encountered at autopsy……………………………………………………………………………… 5
3. Specific health and safety aspects……………………………………………………………………………… 5
3.1 Preparation and risk assessment…………………………………………………………………………………. 7
3.2 Risk assessment……………………………………………………………………………………………………….. 7
3.3 Cases in which death may be due to COVID-19 infection but in which infection
is not confirmed ……………………………………………………………………………………………………………… 7
3.4 The autopsy suite and its facilities………………………………………………………………………………… 8
3.5 Critical decision on undertaking a potential or known HG3 infection autopsy ………………………. 8
3.6 Staff in attendance…………………………………………………………………………………………………….. 9
4. Clinical information relevant to the autopsy………………………………………………………………… 9
5. The autopsy procedure and PPE………………………………………………………………………………… 9
5.1 Behaviour and technique ……………………………………………………………………………………………. 9
5.2 Universal precautions and PPE………………………………………………………………………………….. 10
5.3 Additional personal protection……………………………………………………………………………………. 11
5.4 Limited autopsies…………………………………………………………………………………………………….. 11
6. Diagnosis of COVID-19 infection ………………………………………………………………………………. 11
6.1 How to take these samples……………………………………………………………………………………….. 12
7. Clinicopathological summary and notification of infection…………………………………………. 12
7.1 Other useful contacts ……………………………………………………………………………………………….. 12
8. Recommendations…………………………………………………………………………………………………… 13
8.1 Summary ……………………………………………………………………………………………………………….. 13
9. References ……………………………………………………………………………………………………………… 14
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1. Introduction
This brief guidance has been produced by RCPath following the outbreak of the COVID-19
infection in China. It is produced to aid mortuary staff and pathologists in deciding if a post-mortem
examination is appropriate on a possible COVID-19 death and to advise them on the possible risks
associated with such a case and how to reduce these risks. It also covers diagnosis of COVID-19
at post-mortem examination.
In general, if a death is believed to be due to confirmed COVID-19 infection, there is unlikely to be
any need for a post-mortem examination to be conducted and the Medical Certificate of Cause of
Death should be issued.
1.1 Categorisation of infectious hazard
The categorisation of infectious hazards across all areas of medicine is regulated by the Health
and Safety Executive’s (HSE) Advisory Committee on Dangerous Pathogens (ACDP).1 The
schedule is regularly reviewed and updated in the light of global epidemiological trends. All agents
encountered across the globe are considered, not just those prevalent in the UK. Since
international travel is the norm, people with a potentially lethal infection can now travel from any
one country to any other within 24 hours, and present ill or moribund to a healthcare centre.
There are four hazard groups (HG) of infectious biological agents, categorised along three
considerations:
• the likelihood that it will cause disease by infection or toxicity in humans
• how likely it is that the infection would spread to the community
• the availability of any prophylaxis or treatment.
This categorisation is primarily aimed at workers in diagnostic microbiology laboratories and
infection research laboratories. Mortuary workers are not the main focus, but over recent decades,
we have adapted autopsy practice to reflect the seriousness of many infections that could be
transmitted from the bodies of the deceased during dissection, reconstruction, viewing, handling
and embalming (‘Safe Working’ yellow book, 2003).2
1.2 HG definition: COVID-19
HG3 agents can cause severe human disease and may be a serious hazard to employees; the
agent may spread to the community, but there is usually effective prophylaxis or treatment
available.
The main HG3 agents are listed in Box 1. The infections that cause the most concern in the UK,
and which are considered specifically hereon, are highlighted in bold.
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Box 1: HG3 agents.
Viruses
• Rabies and Lyssa
• Middle East respiratory syndrome coronavirus
• Severe acute respiratory syndrome coronavirus
• COVID-19 (from China 2020)
• Acute haemorrhagic conjunctivitis
• Poliovirus
• Lymphocytic chorio-meningitis
• Rift Valley fever
• Dengue viruses
• Japanese encephalitis
• Tick-borne encephalitis
• West Nile fever
• Yellow fever and yellow fever inactivated virus vaccine
• Hepatitis viruses B, C, D and E
• Monkey pox
• Human T-cell lymphotropic viruses 1 and 2
• Human immunodeficiency viruses 1 and 2
• Chikangunya virus
The risks to mortuary staff from most of these HG3 infections are minimal when applying standard
universal precautions for prevention of infection, and there is no reason why any of the infections
cannot be worked on in a well-appointed mortuary with experienced staff.
1.3 Scope of these guidelines
• To advise those who work in mortuaries on the rational approach to possible COVID-19
cases and when to refer a particular case to a more specialist mortuary.
• To improve the facilities of mortuaries, reducing the likelihood of accidents involving
dangerous infections.
• To recommend advance planning for infection contingencies, with preparation of standard
operating procedures (SOPs) that cover the main anticipated infections.
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• To recommend which levels of staff experience should be mandated for undertaking risky
manoeuvres (e.g. evisceration) in certain HG3 infection cases.
• To indicate safe personal protective equipment (PPE) when conducting possible COVID-19
cases.
• To indicate the optimum evaluation pathways for diagnosing COVID-19 infection.
1.4 Target users and health benefits of these guidelines
The target primary users of these guidelines are pathologists, trainees, anatomical pathology
technologists (APTs) and onsite managers in the mortuary. The recommendations will also be of
value to hospital managers with oversight responsibility of a mortuary, local authority mortuary
managers and coroners.
The outcomes, if the recommendations are implemented, include:
• more refined appreciation of the infection risks presenting in possible COVID-19 cases
• systematic preparation of protocols to manage possible COVID-19 cases.
2. Pathology encountered at autopsy
Although this document is not the place to depict in systematic detail the clinical pathology of all
the HG3 infections, it is useful to describe some of the gross pathological features that could signal
the presence of HG3 and HG2 infections when not previously known. Post-vaccination fatalities,
HIV disease and rabies are also specifically considered.
Table 1: Likely pathological features of COVID-19 infection.
Organ/tissue Pathological features Potential HG3/HG2 infection
Chest Purulent pleurisy, pericarditis and
consolidated lung lobes
Acute lung injury +/- secondary bacterial
pneumonia
Bacterial infections
COVID-19 and MERS
infections
3. Specific health and safety aspects
The critical issues in managing HG3 infections in the mortuary revolve around:
• preparation for the possible presence of an infection in the deceased
• drafting of appropriate and agreed protocols on what to do
• the state of the mortuary and its equipment
• PPE
• preventive prophylaxis through vaccination of staff.
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Inhalation Oral mucosa
CJD (?) CJD (?)
Anthrax ++ TB +
TB +++ HIV +
COVID-19 +++ Anthrax +
Skin surface Inoculation
TB ++ CJD (?)
COVID-19 (?) Fungi +
HIV ++
Anthrax ++
TB +++
HCV +++
HBV +++
Secondary issues include:
• whether junior staff (trainees) should be involved
• whether pregnant staff are at significant risk
• management of accidents in mortuary when working on infected cadavers
• appreciation that bodies can conceivably be contaminated after death with HG3 and HG4
infections, for example in a bioterrorist attack.
In the mortuary, infections may be acquired via:
• percutaneous inoculation
• skin contamination without inoculation
• ingestion
• inhalation
• contamination of mucosal surfaces (eye, mouth, nose).3
The relative risks of acquiring HG3 infections in a mortuary by the routes listed above were
evaluated decades ago. This was before treatments for HIV and hepatitis viruses were available,
and when the infection loads of these HG3 infections were high in the deceased. Figure 1 lists the
routes of infection that are linked to higher risks of acquiring a specific infection after exposure.3
Figure 1: Infectious agents with high risk of acquisition via route of infection.
The increasing relative risks of acquisition are indicated by +, ++ or +++. It should be noted that HIV and
HCV are essentially non-infectious in people undergoing effective chemotherapy, since the body fluid viral
loads are undetectable.
High risk of
acquisition via…..
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3.1 Preparation and risk assessment
To perform HG3 autopsies safely and satisfactorily, it is essential that the following are in place:
• universal standard precautions
• routine risk assessment
• knowledge of the diseases one may encounter
• SOPs for managing specific high-risk infectious autopsies.
The use of universal precautions (see section 5.2) effectively protects against most risks and may,
in practice, render much of the pre-autopsy risk assessment unnecessary. Similarly, universal
precautions protect against a number of other diseases in the post-mortem setting, including
staphylococcal infection, salmonellosis and vancomycin-resistant enterococci. However,
consideration of the risks in each case remains important.3 The safe working guidance2 includes
further information on this procedure.
3.2 Risk assessment
Practitioners have a duty under COSSH to carry out risk assessments of each case. This is to
prevent actions that may put healthcare workers at risk. Pre-autopsy risk assessment may
include:3
• the clinical history on a consent form
• the history as provided by a coroner
• direct information from the treating clinicians
• pathological information from a laboratory database, e.g. positive infection serologies, etc.
• information from hospital infection control
• information on an infection notice proforma that should accompany each cadaver to the
mortuary
• external examination of the body. An emaciated cadaver or the presence of unusual skin
rash may indicate HIV infection; the presence of injection marks on the skin could be the
result of intravenous drug use, which is associated with an increased risk of infections.
In general, if a death is believed to be due to confirmed COVID-19 infection there is unlikely
to be any need for a post-mortem examination to be conducted and the Medical Certificate
of Cause of Death should be issued.
3.3 Cases in which death may be due to COVID-19 infection but in which
infection is not confirmed
The criteria to assess whether a death may have been due to COVID-19 infection but in
which COVID-19 infection has not been proved prior to death are the same as those used to
assess the possible infection risk in the living, but with the caveat that the times referred to
in the guidelines refer to the time before death or a relevant illness developing prior to
death developing. These criteria are available through the following link:
Pub February 2020 8 V1 Final
www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-ofpossible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhannovel-coronavirus-wn-cov-infection – interim-definition-possible-cases
NB: these criteria and the Public Health England guidelines referred to in this document
generally are updated regularly and should be checked when risk assessing each possible
case.
If by using these criteria it is felt that a death may be due to COVID-19, the decision as to
whether to proceed to post-mortem examination and whether that examination is limited
just to obtaining the necessary swabs and samples to confirm COVID-19 infection (as
detailed below) or should entail a fuller more invasive post-mortem examination should be
taken on a case-by-case basis depending on the needs of the coroner and other relevant
parties. The possibility of conducting a staged post-mortem examination to first take the
samples to assess for COVID-19 infection and only after these results have been assessed
moving on to a fuller more invasive post-mortem examination as required should be very
seriously considered and is recommended if at all possible.
3.4 The autopsy suite and its facilities
The safe working guidance2 indicates that having a separate high-risk suite is ideal but not
mandatory for HG3 autopsies. Good ventilation is required in the working areas (autopsy table and
dissection bench), as well as adequate space away from other activities.
Whole room ventilation with the draught passing from ceiling height down and across the tables,
exiting at floor level, is suitable. Alternatively, down-draft tables work well.3 Electric skull saws all
now come with vacuum evacuation into a separate chamber.
It is essential to have all the necessary equipment to hand to avoid the need to leave the area to
find additional items. For example, containers for all anticipated samples must be available,
including sterile plastic bottles for fresh tissues and fluid, and blood culture bottles (aerobic and
anaerobic).
The NHS Estates regulations on mortuary facilities are published in HBN 20. Facilities for mortuary
and post-mortem room services (3rd edition, 2005).
4
3.5 Critical decision on undertaking a potential or known HG3 infection
autopsy
The critical decision is whether or not to proceed with the autopsy examination. The following
conditions must be fulfilled to proceed with the autopsy:
• the mortuary is sufficiently well-equipped, safe and accredited
• the APTs are comfortable with continuing the examination
• the pathologist has knowledge of what they might encounter in the organs and how to
proceed with sample selection and then interpretation of the histopathology.
If these conditions are not fulfilled, then either a more experienced pathologist may be invited to
perform the autopsy in the same mortuary, or the case may be referred to another mortuary that is
appropriately equipped and staffed.
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The issues are:
• an autopsy is the only opportunity to observe the organs and take optimal samples. It is
usually too late to take additional samples after the initial autopsy if the original samples were
inadequate to identify what infections are presence and causing disease.
• inexperience and lack of upfront protective practices are risk factors for accidentally acquiring
potentially severe infections.
SOPs should be generated by mortuaries to cover all the common and uncommon autopsy
scenarios.
3.6 Staff in attendance
According to the safe working guidance,2 the team undertaking a high-risk infectious autopsy
should ideally include a circulator assistant in addition to the pathologist and APT (although this is
not mandatory). The circulator assistant carries out auxiliary tasks such as sample labelling.3
Nowadays, circulators are rarely available.
Pathology trainees can undertake high-risk infection autopsy work under supervision by senior staff
and when they have demonstrated knowledge of the risks and safe protection practices. In the
authors’ unit, junior trainees do not eviscerate HG3 cases, but can dissect the organs after
removal. Essentially, if the senior staff have confidence in the trainee’s experience and knowledge,
they can proceed with such autopsies.
Although there is no particular infection risk to pregnant trainees if standard universal precautions
are followed, they may wish to remove themselves from mortuary work. The deanery may need to
be informed of this decision.
4. Clinical information relevant to the autopsy
Information about the circumstances of a death that requires an autopsy is key. In addition to
standard clinical information and location of death, knowledge of past international travel,
laboratory data and microbiology data (positive and negative) are critical. It is important not to
assume that the information provided is accurate. There have been many cases in which an
unanticipated HG3 became manifest at autopsy. Likewise, there have been many cases where a
confident clinical statement that the patient had (for example) active TB, or even HIV, turned out to
be untrue.
5. The autopsy procedure and PPE
For most HG3 infections (known or suspected), a standard systematic external and internal organ
examination procedure is appropriate. In cases of blood-borne infections, the presence of multiple
hands within the cadaver should be avoided to prevent accident.
5.1 Behaviour and technique
Knowledge of the potential hazards that may be encountered determines the approach to a HG3
autopsy. It is essential that training is provided and safe practice is demonstrated. Some
mortuaries forbid trainees to operate on any HG3 infection deceased bodies , yet on appointment
to consultant status, they will find themselves rapidly involved in such cases. Trainee APTs usually
Pub February 2020 10 V1 Final
undergo a more structured introduction to this work, in line with their curriculum and the Royal
Society for Public Health (RSPH) diploma. It is recommended that pathology trainees are inducted
in similar fashion, with regular instruction on safe practice.
The following are part of universal precautions in autopsy dissection practice:3
• round-ended scissors should be used
• PM40 blades with blunted points reduce prick injuries
• sharps in the working area should be kept to a minimum and their whereabouts known at all
times
• practitioners should operate within the body cavity one at a time
• unfixed organs must be held firm on the table and sliced with a sponge – care should be
taken to protect the hand
• an oscillator saw with suction extraction of the bone aerosol into a removable chamber
should be used for sawing the skull; alternatively, a hand saw with a chain-mail glove may be
used
• needles should not be re-sheathed after fluid sampling – needle and syringe should be
placed in a sharps bucket.
5.2 Universal precautions and PPE
All employers have to protect the health and safety of their employees under the Health and Safety
at Work Act 1974. PPE is essential. It is standard for all autopsies that pathologists and APTs wear
the following:3
• surgical scrub suit
• hat to protect hair
• clear visor to protect the face, eyes and mouth
• respiratory protection, either as a standard surgical mask or a FFP3 mask, which more
effectively excludes small particles of infective material
• a waterproof gown that covers the entire body, including the forearms
• a plastic apron over a waterproof gown
• rubber boots with metal-protected toecaps and dorsal reinforcement
• or other equivalent material gloves
• under single use disposable non-latex gloves, protective gloves made of kevlar or neoprene,
which are cut-resistant in case of potential blood-borne infection. This is increasingly
standard practice in UK mortuaries.
PPE gives as much protection as reasonably possible against the majority of HG3 infections,
including blood-borne viral agents. Only infective aerosols (e.g. TB) are not 100% protected
against.3
Pub February 2020 11 V1 Final
5.3 Additional personal protection
Surgical masks do not provide adequate protection against air-borne infections entering the
respiratory tract. FFP3 masks are designed to be over 95% effective. FFP3 masks are appropriate
for suspected COVID-19 infection cases. Full body suits that include a powered air-purifying
respirator with high-efficiency particulate air filters essentially provide 100% protection.3 However,
this is unnecessary and logistically unrealistic. In the authors’ unit, this equipment is used mainly
for examining chemical toxic deaths such as cyanide poisoning.
5.4 Limited autopsies
There has been much research on the utility of limited autopsies (i.e. needle sampling or single
opening organ sampling) in the context of autopsy practice in resource-poor countries with limited
mortuary facilities and staff. Such minimally invasive autopsies (MIA) are undoubtedly useful in
cases of systemic infection by viruses and bacteria, where sampling blood, liver and spleen will
reliably provide diagnostic samples.5 However, when infections are focal, the use of MIA as a blind
technique is limited.
6. Diagnosis of COVID-19 infection6
Samples for diagnosing cases of COVID-19 at post-mortem examination are identical to
those used to make the diagnosis in life and consist of upper respiratory tract swabs (viral
nose swab, viral throat swab), lower respiratory tract (sputum, BAL) and a plain tube of
blood for serology. Full guidance on samples suitable for making a diagnosis of COVID-19
can be found at: https://www.gov.uk/government/publications/wuhan-novel-coronavirusguidance-for-clinical-diagnostic-laboratories
The guidance includes all the necessary specific information on organising such testing
including how to package samples, where to send them and how to contact the laboratory
involved with testing by email with the relevant proforma, etc. There is a specific E28
request form that should be used; there is a box to tick for post-mortem samples. The form
can be found at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_d
ata/file/862474/PHE_VRD_laboratory_testing_request_form_E28_for_2019-nCoV.pdf
Specific post-mortem guidance obtained from Public Health England states that ‘it would be
helpful if you were able to swab the upper respiratory tract with one swab, and conduct a
swabbing of the internal lungs on another swab. Lung tissue could be taken at the time of
swabbing, but if the swabs are negative then the tissue would not be tested. Please note
that each sample requires its own E28 form.’
Further information can be obtained at WNCoV.virology@phe.gov.uk or the following
address:
Respiratory virus unit (RVU)
Public Health England
61 Colindale Avenue
London
NW9 5EQ
Tel: 020 8327 6017
Fax: 020 8205 8195
Pub February 2020 12 V1 Final
In addition to the specific samples taken for COVID-19 testing, we recommend standard
samples, including swabs and tissue samples from the respiratory tract, be sent locally for
microbiology/virology to assess for other infectious agents. Furthermore, we recommend a
full set of tissue samples are taken for histology together with other samples for other
investigations taken as appropriate and defined on the merits of the case.
6.1 How to take these samples
Urine, blood and cerebrospinal fluid (CSF) need to be taken as cleanly as possible, and before
opening any cavity of the body, to reduce contamination of skin. The skin sample site can be
cleaned with alcohol-containing swabs.
Blood for bacterial culture must be taken from above the umbilicus to reduce faecal contamination.
Thus, take it from subclavian or jugular veins, or from the heart left ventricle through the sternum.
Pre-prepared sample sticks can be used for nasal swabs and submitted immediately for PCR
influenza virus identification.
7. Clinicopathological summary and notification of infection
If infection was the main cause of death, it needs to be stated in the bottom line of part 1 of the
cause of death sequence; specific organ lesions may or may not need to be stated, depending on
the case. If infection contributed to the death, but is not the main cause, then placing it in part 2 is
appropriate.
Public Health England should be notified of any confirmed case of COVID-19; however, this will be
done by the laboratory making the diagnosis.
7.1 Other useful contacts
Wales
Public Health Wales
2 Capital Quarter
Tyndall Street
Cardiff
CF10 4BZ
Tel: 0292 022 7744
Email: general.enquiries@wales.nhs.uk
Website: https://phw.nhs.wales/
Northern Ireland
Public Health Agency
Linenhall Street Unit
12-22 Linenhall Street
Belfast
BT2 8BS
Tel: 0300 555 0114
Website: www.publichealth.hscni.net/
Pub February 2020 13 V1 Final
Scotland
Gyle Square
1 South Gyle Crescent
Edinburgh
EH12 9EB
&
Meridian Court
5 Cadogan Street
Glasgow
G2 6QE
Tel: 0141 414 2888
8. Recommendations
1. Knowledge, experience and preparation are the key aspects in managing any possible
COVID-19 post-mortem examination.
2. COVID-19 is an HG3 infection.
3. All the staff – pathologists and APTs – must be aware and in agreement with protocols to
manage such cases.
4. Preparation of appropriate protocols for safe and effective practice are essential.
5. Suitable PPE should be worn.
6. Mortuaries must have appropriate blood, CSF and tissue sampling technical systems and
access to appropriate microbiology and virology laboratory facilities.
7. Nasal swabs are the preferred method for confirming COVID-19 infection. These can be
supported by assessment blood and tissue samples.
8. If an unexpected infection becomes apparent during an investigation that is beyond the
experience of the pathologist, they must seek advice and assistance from the UK network of
experts.
8.1 Summary
See Figure 1 for infection risk data. Table 2 summarises the PPE that should be worn.
Table 2: Recommended PPE for COVID-19.
Infection Facial protection Hand protection
COVID-19 FFP3 mask and eye protection Neoprene cut-resistant glove under rubber
gloves
Pub February 2020 14 V1 Final
9. References
1. Health and Safety Executive Advisory Committee on Dangerous Pathogens. The Approved
List of biological agents. Accessed April 2018. Available at:
www.hse.gov.uk/pubns/misc208.pdf
2. Health and Safety Executive. Safe working and the prevention of infection in the mortuary
and post-mortem room. Accessed April 2018. Available at:
www.hse.gov.uk/pubns/books/hsg283.htm
3. Lucas S. Autopsies on people with high-risk infections. In: Burton JL, Rutty G (eds). The
Hospital Autopsy: A Manual of Fundamental Autopsy Practice (3rd edition). London, UK:
Hodder Arnold, 2010.
4. The NBS. HBN 20 Facilities for mortuary and post-mortem room services (3rd edition).
Accessed April 2018. Available at:
www.thenbs.com/PublicationIndex/documents/details?Pub=NHS&DocID=275892
5. Castillo P, Martinez MJ, Ussene E, Jordao D, Lovane L, Ismail MR et al. Validity of a
Minimally Invasive Autopsy for Cause of Death Determination in Adults in Mozambique: An
Observational Study. PLoS Med 2016;13:e1002171.
6. Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DKW et al. Detection of 2019
novel coronavirus (2019-nCoV) by real-time RT-PCR. Eurosurveillance 2020;25:23.
Available at: www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.3.2000045
