This document provides specific interim recommendations for the collection and submission of postmortem specimens from deceased persons with confirmed or suspected COVID-19. This interim guidance is based on what is currently known about coronavirus disease 2019 (COVID-19), including what is known regarding how SARS-CoV-2 spreads.
Medical examiners, coroners, and other healthcare professionals should use professional judgment to determine if a decedent had signs and symptoms compatible with COVID-19 during life and whether postmortem testing is necessary. Many patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., fever, cough, difficulty breathing). There are epidemiologic factors that may also help guide decisions about testing for SARS-CoV-2, such as documented COVID-19 in a jurisdiction, known community transmission, contact with a known COVID-19 patient, or being a part of a cluster of respiratory illness in a closed setting (e.g., a long-term care facility). Testing for other causes of respiratory illness (e.g., influenza) is strongly encouraged, see Information for Clinicians on Influenza Virus Testing.
In addition to postmortem specimens, any remaining specimens (e.g., NP swab, sputum, bronchoalveolar lavage) that were collected prior to death should be retained. Please refer to Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19 for more information.
If a postmortem NP swab is being collected, only those personnel who are obtaining the specimen should be in the room. Personnel should follow Standard Precautions. In addition to Standard Precautions, the following are recommended:
For suspected COVID-19 cases, CDC recommends collecting and testing postmortem NP swabs and if an autopsy is performed, lower respiratory specimens (lung swabs). If the diagnosis of COVID-19 was established before death, collection of these specimens for COVID-19 testing may not be necessary. Medical examiners, coroners, and pathologists should work with public health or clinical laboratories to determine capacity for testing postmortem swab specimens.
There are limited data available to estimate the frequency of detection of SARS-CoV-2 by RT-PCR by swabs collected at different intervals postmortem. If SARS-CoV-2 testing on postmortem swab specimens is being considered for a suspected COVID-19 case, SARS-CoV-2 RNA may still be detected up to several days postmortem and possibly longer, based on limited available data for SARS-CoV-2 and from experiences with MERS-CoV and SARS-CoV. Sensitivity may be reduced with a longer postmortem interval or embalming. Duration of illness prior to death should be considered when interpreting a negative result.
Studies that evaluate the detection of SARS-CoV-2 by antigen testing on postmortem swabs are being reported in the literature. The sensitivity of rapid antigen tests is generally lower than NAAT. Please refer to Interim Guidance for Rapid Antigen Testing for SARS-CoV-2 for more information.
If multiplex assays for the simultaneous detection of SARS-CoV-2, influenza viruses and other respiratory pathogens are not available, separate postmortem specimens (e.g., NP or lung swabs) should be collected for routine testing of respiratory pathogens at either clinical or public health labs. Note that laboratories should NOT attempt viral isolation from specimens collected from confirmed or suspected COVID-19 cases unless this is performed in a BSL-3 laboratory.
No data are currently available on performance of SARS-CoV-2 serologic testing on postmortem samples. Serologic tests for SARS-CoV-2 look for the presence of antibodies. In general, a positive antibody test is presumed to mean a person was infected with SARS-CoV-2, the virus that causes COVID-19, at some point in the past or developed antibodies from receiving a COVID-19 vaccine. It does not mean they are currently infected. Antibody tests can detect the presence of these antibodies in serum within days to weeks following acute infection. Depending on when someone was infected and the timing of the test, the test may not find antibodies in someone with COVID-19 at the time of death. Antibody test results should not be used to diagnose someone who is suspected to have an active, current SARS-CoV-2 infection. For more information, see: Interim Guidelines for COVID-19 Antibody Testing.
If necessary and with advance approval, postmortem swab specimens may be shipped to CDC for SARS-CoV-2 RT-PCR testing if testing is not available at public health or clinical laboratories in a jurisdiction, or if repeated testing results remain inconclusive, or if other unusual results are obtained. State or local health departments should contact CDC at firstname.lastname@example.org prior to submitting samples to confirm.
Standard body bagging procedures should be followed, consistent with procedures used for deaths when there is no confirmed or suspected COVID-19. Given the varying weights of decedents and variety, construction, and conditions of body bag materials, postmortem care workers should use prudent judgement determining if risks for puncture, tearing, or failure of body bags could occur and whether a second body bag or a body bag of thicker, stronger material (e.g., minimum of 6 mil thickness) is necessary. Risk factors include:
VINCENT DiMAIO, M.D., Fmr. Chief Medical Examiner, San Antonio, TX: A lot of people see TV and CSI, and they think that's how it really is. But really, it varies from excellent to absolutely lousy. I mean, when you look at a case as a forensic pathologist and you say, "Oh, oh, there's no scientific basis for this decision. It's just complete garbage." And then you have a family that looks at it and it's typed on this neat paper and there's this official seal, and they say, "I guess they know what they're doing."
Dr. MARCELLA FIERRO: There are coroners trying to carry out death investigations, but they don't have the training, they don't have the money, they don't have the infrastructure, and they don't have the skill. I guess you really have to ask yourself, do you want your cause of death and your manner of death to be decided by someone in medicine who has special competency to do that?
JOEL SEXTON, M.D., Forensic pathologist: The autopsy was done outdoors in a old garage behind the hospital. It was sometimes very hot, particularly this time of year, like in August. And recognize that once a body starts decomposing, it's almost accelerated with heat.
LOWELL BERGMAN: [voice-over] But we have found new cases that reveal cracks in Coroner Minyard's "palace of truth," like the case of Cayne Miceli. On the morning of January 4, 2009, here at Tulane Medical Center, 43-year-old Cayne Miceli came into the emergency room suffering from a severe asthma attack. When the staff tried to discharge her even though she was still having trouble breathing, Cayne, who had a history of psychiatric problems, resisted, and the hospital called the authorities.
According to the house of detention's own records, Cayne told the staff that she couldn't breathe. As she struggled, she began to get free. So four guards held her down. Only when they could no longer find a pulse were paramedics called. They rushed Cayne to the hospital. And that's when her father, Mike, was notified.
Dr. MARCELLA FIERRO: I think many people only get that realization when it actually touches them, when they have a family member who dies violently and they want to know what happened. And if when there are good answers to those questions, people are grateful. If there are not good answers, there's no place for them to go to get an answer. So they have to take what's out there.
The Miyake-Apple technique for posterior photography and video analysis of postmortem eyes and its variations provide a unique view of the anterior segment structures and surgical manipulations that are not readily seen during surgical procedures or by clinical inspection. It is particularly useful in studying and teaching anterior segment surgery, especially cataract and intraocular lens (IOL) surgery. We summarize the peer-reviewed literature on the use of this technique (1) in experimental studies with fresh human or animal eyes to analyze new IOLs and surgical techniques, (2) in formalin-fixed human pseudophakic autopsy eyes to study IOL-related complications, and (3) for teaching and training purposes.
The roughly hourlong video repeatedly flashes across the screen what appear to be postmortem blood clots, which are often found in dead bodies. Although such clots are common, the video features nine embalmers and funeral directors who describe the clots as a new anomaly and surmise that they were caused by COVID-19 vaccines. The video suggests that this is part of a shadowy plot to depopulate the world.
The doctors, hospitals and other healthcare services of the Sutter Health network provide a consistent level of exceptional, personalized care to patients and often receive awards for the quality care they provide.
Personal protective equipment (PPE) used for a COVID-19 postmortem examination. Head cover, shoes cover, leg cover, Tyvek chemical protection coverall (Cat. III), impermeable gown, plastic protective goggles, 3 pairs of surgical sterile gloves, 1 pair of powder-free nitrile gloves, FFP3 protective face mask
Surgical models are invaluable resources for training and for research and innovation. In the field of supermicrosurgery (SM), options for surgical models remain limited and imperfect. We report the use of a fresh, previously frozen 4-week postmortem cadaveric specimen for successful distal to proximal indocyanine green (ICG) lymphography of the upper extremity. Our technique was confirmed with handheld SPY fluorescence imaging, which visualized a clearly defined, linear lymphatic system. By outlining a straightforward, reproducible method of lymphatic mapping in cadaveric specimens, our group aims to expand the frontiers of surgical models for SM. 2b1af7f3a8