key: cord-0881752-2a51ph3s
authors: Manzanares‐Céspedes, Maria‐Cristina; Dalmau‐Pastor, Miki; Simon de Blas, Clara; Vázquez‐Osorio, María Teresa
title: Body donation, teaching and research in dissection rooms in Spain in times of Covid‐19
date: 2021-04-23
journal: Anat Sci Educ
DOI: 10.1002/ase.2093
sha: ed71845ff337e57d553b38278b4b2ad15daeaddb
doc_id: 881752
cord_uid: 2a51ph3s

The state of alarm due to Covid‐19 pandemic in Spain stopped all educational and most university research activities. The Spanish Anatomical Society (SAE) Consensus Expert Group on Body Donations piloted a study based on a questionnaire to know the status of body donations and dissection activities during the lockdown, as well as the future implications of Covid‐19 pandemic for body donation programs and Anatomy teaching. The questionnaire results show that Spanish Universities refused body donations and stopped all dissection research and teaching. The Covid‐19 expected influence on Anatomy teaching was referred to the increase of teaching workforce and resources required to apply the new safety measures to future practical activities, as well as to prepare and adapt teaching material for online‐only programs. The application of reinforced safety measures was expected to be perceived by the respondent’s students as a gain in teaching quality, while the transformation of the anatomy courses in online‐only programs will be perceived as a quality decrease. The respondent’s concerns about future institutional implications of the pandemic were related to increased costs of the adaptation of the facilities and the reinforced preventive measures, as well as the eventual decrease in donations. The complete lockdown applied on dissection rooms is not justified by scientific evidence and represents a break of the confidence deposed in the institutions by the donors. A consensus is required for the adoption of a renewed, comprehensive protocol for present and future body donations including the evidence Covid‐19 pandemic has contributed to create.

The pandemic situation caused by the novel Coronavirus originated in the Chinese city of Wuhan in December 2019 has changed everyday life as well as academic life around the world (Li et al., 2020; Burgess and Sievertsen, 2020; George et al., 2020) . This virus was termed Covid-19 and caused the World Health Organization to declare a public health emergency on January 30, 2020 (Mahase, 2020) . The spread of the disease in Europe was very swift, and the state of alarm was decreed in Spain on 14 March 2020. With immediate effect educational and university research activities were stopped in the national territory. The lockdown of the population, the elevated mortality of and the restrictions applied to burial and cremation procedures made the management of ordinary body donations very complicated. In addition, since all Spanish universities (50 public, 26 private) decreed a complete closure of services and installations, the administrative procedures for the management of the donations were suspended. Similar situations have been reported at a global level as a consequence of the pandemics Gupta and Pandey, 2020; Longhurst et al., 2020; Ooi and Ooi, 2020; Pather et al., 2020; Ravi, 2020; Singal et al., 2020, Bond and Franchi, 2021; Onigbinde et al., 2021) The immediate and dramatic impact of the Covid-19 pandemic in the Health Sciences Education at all levels has been a matter of deep concern for both academia and students faced with the closure of the practical anatomy laboratories and clinics during the full-lockdown period. The sudden transformation of face-to-face (F2F) teaching on a completely online one required a great deal of flexibility and effort from both health sciences teachers (Iyer et al., 2020; Longhurst et al., 2020; Moskowitz et al., 2020; Pather et al., 2020; Quinn et al., 2020; Iwanaga et al., 2020; Saverino et al., 2021; ) and students (Franchi, 2020; Srinivasan, 2020) . In Spain, dissection rooms are used by a variety of students including medicine, nursery, dentistry, physiotherapy, podiatry, and by post-graduate students attending surgical training courses.

In Spain, dissection rooms (DR) and body donation programs (BDP) are managed by universities, under the administrative tutelage of the autonomous governments, as is the case for public health services. Cadaver and organ donation options are included in the living will documents elaborated by

This article is protected by copyright. All rights reserved most autonomous governments (BOE, 2002) . Since 1992, Spain has maintained the world record for organ donations, attaining 48 PMP (per million population) donors in 2019, as compared with the PMP values reported by the United States (32, 8) , Australia (22, 3) and the European Union from Greece, 4,1 to Portugal, 33,4 (ONT, 2020) . The living will includes the possibility of donating the body if organ donation for transplantation is not feasible. This simplified administrative procedure constitutes the main reason of the increase in body donations experienced by all Spanish BDPs in the last decade. However, there is a lack of a common legislation at a national level to regulate the use of donation cadavers for academic activities, and the sole national law to regulate the management of dead bodies dates from 1974 (BOE, 1974) . Consequently, there is not a national register of donations.

In order to address the legal aspects, as well as the necessity of a common regulatory structure for the body donation programs, the Spanish Anatomical Society (SAE) constituted in 2018 an expert group to elaborate consensus documents about the management, the administration and the ethical implications of cadaver donation. This group informed to the General Assembly of the Society, held virtually the 11 May 2020, of the situation caused by the state of alarm and the lockdown status on the dissection rooms, that remained closed in all Spanish higher education institutions with the only exception of the Complutense University of Madrid. The director of this body donation center informed that they had requested the advice of the University legal services. The answer was that "the commitment acquired with the donor, once he/she has expressed his/her will to donate his body after his/her death, constitutes a contract between the two parts, that the University and the BDP are forced to fulfill under any circumstance". As a consequence, the BDP was decreed as a "critical" service by the Rector of the Complutense University. All public and private services decreed as critical were legally allowed to remain open to operate during the different lockdown phases, thus the Complutense University BDP is the only one in Spain receiving donations to date.

However, despite existing clear indications from the Spanish Government as how the bodies of the victims from Covid-19 should be handled (SEAP-IAP, 2020) , and the existence of numerous national laws (CDC, 2020; Government of India, 2020; UK Law, 2020) international regulations (ECDC, 2020; Kramer et al., 2020; WHO, 2020; Finegan et al., 2020) 

This article is protected by copyright. All rights reserved (FICEM 2012; Sañudo, 2015; Vázquez-Osorio, 2020; RCP, 2020) about the best practices in the handling, management and preventive measures to apply to cadavers, most Spanish Universities suspended all BDP activities.

The situation was discussed by the SAE General Assembly that resolved that a survey will be proposed to all attending BDP Directors. A questionnaire was prepared in order to assess the situation of the teaching and research activities in the dissection facilities, as well as the expert group members and BDP director's perceptions about the influence of the Covid-19 pandemics and the consequent increase in preventive measures will have in the future academic activities to be carried out in the dissection rooms. The present paper reports the results of this questionnaire about the status of the dissection activities in the respondent's institutions. This analysis is aimed to facilitate the discussion on the proposed changes on the donation protocols and procedures that will be included in the SAE consensus documents about the management, the administration and the ethical implications of cadaver donation.

The aim of this survey was to get a clear picture of the initial measures taken by the BDPs about the donations as well as the activities of the DRs in response to the Covid-19 crisis. The purpose of this survey was to provide information to the SAE expert group to discuss the eventual need to propose changes on the cadaver donation process in the Spanish Universities, and to determine the scientific evidence supporting the decisions taken as a consequence of the Covid-19 pandemics.

An electronic ad hoc 15-items questionnaire was designed and piloted by the SAE, in order to know the situation in the DRs with respect to teaching and research activities during the initial lockdown of the academic institutions, and the perceptions of the participants about the next academic year.

The questionnaire was designed in Spanish language and used single-answer or multiple-choice questions to assess the current institutional decisions taken about the management of the DRs and the body donation programs, the future implications of the Covid-19 pandemics on the BDPs and on the

This article is protected by copyright. All rights reserved teaching of Anatomy as well as on the perception of the SAE members about the eventual loss of confidence of the students on the quality of the anatomical education as a consequence of the Covid-19 situation. An English translation of the questionnaire is available as Supplemental Material File Appendix 1 to this manuscript.

Once reviewed, the questionnaire was approved by the Bioethics Committee (Institutional Review Board) of the University of Barcelona. The questionnaire was then distributed to the SAE expert group on body donations and DR management. The survey was launched on 25 May 2020, and this initial analysis reports the data collected from the 15 directors of the body donor services until 1 June 2020, analyzed with descriptive statistics.

The purpose of this survey is also to create a map of the responding BDPs to build a community of Spanish institutions dedicated to research and education in human anatomy. Nine responses from a total target population of 15 in Spain, i.e., constituted by the directors of the cadaver centers and anatomic departments that act as such were received. The respondents, from different Spanish regions, were diverse in terms of gender (6 males, 3 females) and seniority (7 seniors, 2 juniors). The seniority was assessed using the same criteria -more than 10 publications in a period of more than ten years-reported by Bennet et al. (2019) .

Although the questionnaire was designed using single-answer or multiple-choice questions, the same criteria were used to categorize all responses in order to compute Kendall's Tau B correlations and Cronbach's alpha (Cronbach, 1951) to assess the validity and the reliability (respectively) of the instrument. All test and data analysis were conducted using SPSS statistical package, version 18 for Windows (IBM Corp., Armonk, NY). Finite Population Correction Factor (FPC) was used to compute the confidence intervals for the percentage of responses in the sample, given in equation below Eq.

(1).

where N is the population size and n is the sample size.

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Kendall's Tau B correlation, a nonparametric measure of the strength and direction of association between two variables was used to assess the significance of the relation between the rankings.

Cronbach's alpha was applied to measure the internal consistency between the items of the questionnaire. A reliability coefficient of 0.6-0.70 or higher was considered "acceptable", and 0.8 or greater a "very good level" as in most social science research (Hulin et al., 2001) .

The survey was applied to a sample of 15 directors of dissection rooms and/or body donation programs and were collected from May 25th to June 1st 2020. During that period 9 directors of body donation programs pertaining to the Spanish Anatomical Society responded, which supposes the 60% of the total population susceptible to respond to the questionnaire (15 donation centers). Therefore, an error sample  = 2.83% was derived considering a significance level α = 0.05 following equation Eq.

(2).

where n is the sample size, N is the total population size, P-value is the proportion (in case is unknown, P = 0.5), is the right tail value for a normal distribution with mean cero and variance 1 2 considering a significance level α (in this case, and  is the error sample. A corrector for 2 = 1.96) finite populations was applied.

As pointed out by Sijtsma (2009) , many psychologists led to the interpretation of alpha as a measure of the internal consistency of a test. The value obtained by the associated Cronbach alpha was 0.702.

The reported data covers four main areas, the first being the current situation and management of eventual Covid-19 cadaver donations. Then, the prevision of the respondents about the future implications of the pandemics in the BDP organization as well as in the teaching of Anatomy. Finally,

This article is protected by copyright. All rights reserved the eventual change in the student's perception on the quality of their anatomic formation due to the pandemic measures, including the eventuality of an online-only academic year.

The directors of DRs and BDPs reported that both the dissection activities and the donation programs in the universities were severely limited ( Table 1) . Majority of respondents (66.7%) reported to be closed both for teaching and for research activities, as well as to receive potential donors and cadaver donations, in application of the complete lockdown active in that period. The exceptions to that general rule were three directors: one reported the possibility of carry out research activities, but no teaching or donations (11.1%); a second one, the possibility of carry out teaching activities, but no research or donations (11.1%); and the third, the possibility to receive cadaver donations, but not to carry out teaching or research activities (11.1%). Interestingly, this last institution was the only one to decree the body donation service as a "critical" one, based on the position of the institutional legal advisors that the donation remains a legally-binding contract between the donor and the Institution.

In a previous meeting of the SAE expert group the main guidelines on the management of cadavers were reviewed, and a consensus was reached as per the redaction of a document reporting a standardized protocol to be adopted by the SAE. Thus, two questions were included regarding the tests and procedures to apply in future donations (Table 1) . About 22.2% respondents reported that the donations were suspended sine die; while 22.2% reported that the cadavers would be directly frozen, while waiting for tests. In addition, 33.3% participants would carry out specific tests, added to the usual protocol (including HIV, Hepatitis and prions) and 11.1% would continue with the usual tests while another 11.1% would submit the cadavers to the usual embalming procedure, which was then reported as the method of choice to avoid crossed contamination (Balta et al., 2015) . A second question aimed to a potential future donation of a donor suspected of Covid-19: this situation was not possible for the 44.4% of the institutions not accepting donations during the questionnaire period. Referring to the institutions accepting donations, one director reported that one of their recent donations included symptoms compatible with pneumonia in the patient's clinical history, and another one revealed his concern about a donation received the 1 st March (before Official

This article is protected by copyright. All rights reserved lockdown) with "Pneumonia" as the reported cause of death. Regarding the possibility of an analytic result confirming the Covid-19 in an already accepted cadaver, 55.6% (5 of 9 respondents) of the answers were negative, while in the 44.4% positive cases, different protocols were to be applied: two services (22.2%) decided the embalming, in one case before freezing the body, while another (11.1%) decided to directly freeze the cadaver and a fourth one (11.1%) opted for declining the donation. Only three cases of accepted body donations with Covid-19 as death cause were reported (33.3%); two of the bodies (22.2%) were froze after embalming, and in one case (11.1%) the donation was declined.

Significant Kendall's Tau B correlations were found between the possibility of future acceptance of cadaver donations during the pandemic and the current situation (correlation 0.695 significant at 0.05 bilateral level), were the 42% opted for freeze the cadaver, the 42% made analytics confirming Covid and in one case no change was adopted with respect to the previous cadaver management procedure.

Therefore, there is a high correlation between future possibility of the center to accept cadavers with Covid-19 as death cause and the current actuation protocol of the center. Centers that are open and currently accept cadavers with Covid-19 as cause of death, would accept bodies with Covid-19 in the future (freezing them or doing tests to confirm the cause of death), while those that are closed or do not accept donations, will not accept bodies in the next time horizon.This resulted also in significant Kendall's Tau B correlations with the attempt to donate a body with the mention of Covid19 as the "cause of death" in the medical record /death certificate (correlation 0.84 significant at 0.05 bilateral level) where in 5 cases (83%) no donations with "Covid-19" as death cause were received and the performance donations with Covid-19 (correlation 0.707 significant at 0.05 bilateral level).The attempt to donate a body with the mention of Covid-19 as a "cause of death" in the medical record / death certificate and the actuation with Covid-19 donations was also significatively correlated (correlation 0.809 significant at 0.05 bilateral level).

When asked about their perception about the impact of the pandemics on the donations, only one of the responders (11.1%) considered that it would not have a noticeable impact. About 33.3%

This article is protected by copyright. All rights reserved participants expected a decrease in future donations, while 55.6% were not able to preview the impact of the situation on future donations (Table 2) .

The need for structural changes in the dissection rooms such as the use of mobile separation systems or devices, due to the new safety requirements of social distance, was reported by 44.4% of the directors (Table 2 ). Another 44.4% (4 of 9 respondents) considered that no changes were required in their respective installations, while, on the contrary, one participant (11.1%) disclosed the need for a complete refurbishment of the dissection room ( Table 2) . None of the responders reported to have received any indication from their respective academic (77,7%) or regional authorities (22,2%) about the need for changes in the dissection room to adapt it to the new Covid-19 preventive measures when the academic activities eventually resume (Table 2) . Table 2 reflects the director's perceptions about the possible increase of costs due to the added preventive measures. About 55.6% (5 of 9 respondents) estimated that costs for the dissections would increase between a 0 and a 20%; 22.2% estimated an increase between the 21 and a 50% of the costs, while 11.1% were unable to estimate the eventual increase and another 11.1% considered that no cost increase was to be expected. Most directors expected that their Institution would cover totally (33.3%) or partially (55.6%) these extra costs, with only one (11.1%) reporting a probable negative answer.

Significant Kendall's Tau B correlations were found between the need for structural changes in the dissection rooms and the consideration that the Institution would cover these extra costs (correlation -0.653 significant at 0.05 bilateral level), were in one case the director (11.1%) consider minimum changes to be totally covered and in two cases (22.2%) expected considerable changes to be partially covered by the Institution. However, in 4 cases (44.4%) the directors didn't consider the need for structural changes. However, they expected a small increase in the dissection rooms costs due to the added preventive measures, to be covered at least partially by the Institution.

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More than half (55.6%) of the participants reported to have a sufficient number of teachers to carry on an online-only anatomy practical course by maintaining its quality, while 44.4% reported a lack of teaching workforce. The same percentages were reported when asked about the material resources available to create, adapt or preserve teaching materials to maintain the teaching quality for a completely online academic year. In addition, 55.6% reported not to have the number of professors required to comply with new safety procedures in terms of reducing the number of students per practical group, while 44.4% reported to have an adequate teaching workforce for these eventual requirements (Table 3) .

To apply the new safety and prevention protocols and social distance while maintaining the teaching quality of the practical courses, personal protective equipment, as well as material resources (tests, disposable dissection material, etc.) are required (Table 3) . Majority (77.8%) of respondents reported not to have those resources available, and only 22.2% reported to be adequately furbished of protective materials.

Significant Kendall's Tau B correlation was found between the availability of a sufficient number of teachers to carry on an online-only anatomy practical course by maintaining its quality in case of impossibility of retake practices in the dissection rooms. Therefore, there is a positive correlation between the teaching workforce at the center to face remote teaching while maintaining the quality of teaching. In other words, centers with high availability may face semi-face-to-face or remote teaching, while centers with low availability foresee a drop in the quality of teaching if no F2F was possible. In four cases the director (44.4%) reported to have enough teachers to carry out online-only teaching whereas in four cases (44.4%) they considered that more personnel was needed to comply with new safety procedures in terms of reducing the number to students in the practical groups for on-site activities.

This article is protected by copyright. All rights reserved Regarding the participants opinion on the student's perception of the quality of the anatomy teaching if all activities were organized entirely online, shown in Table 4 , 66.7% (6 of 9 respondents) reported that this will be perceived as a decrease of the quality of their anatomical teaching. The other 33.3% considered that the perception of the teaching quality by the students will not change. On the contrary, when asked about the student's perception of the teaching quality of the practical courses once the new preventive measures will be applied to the anatomy practical courses, 55.6% (5 of 9 respondents) suggested that this will be perceived as an increase of the quality, while 44.4% reported that no change in the student's perception was to be expected.

No significant Kendall's Tau B correlation was found between both opinions.

A complete cessation of teaching activities at a global level is a new situation, despite some antecedents during previous epidemic outbursts (Patil and Yan, 2003) . It has a major negative impact on the learning process of any student, and that it forces the professorate to rapidly explore new teaching options (Ahmed et al., 2020; Iwanaga et al., 2020; Eberlová and Mansfeld, 2020) . Most of the authors that, as 77.8% of the responders, reported the restriction or the total interruption of anatomy laboratory teaching practices during the pandemics shared also their experiences and the methods and instruments used to adjust their teaching approaches (Moszkowicz et al., 2020; Saverino et al., 2020; Srinivasan, 2020) . The closure of the dissection rooms and the sudden transformation of a very practically-oriented face-to-face teaching on a completely-online teaching has elicited a global debate and some initiatives were proposed to improve the anatomy teaching with the implementation of e-learning methods in a move towards a blended learning approach (Longhurst et al., 2020; Pather et al., 2020) .

The concern of students and professors with regards to a diminution of education value, as well as difficulties with online evaluations became evident (Rose, 2020; Quinn et al., 2020) . The limitation of all practical F2F activities, and its substitution by online-only activities will cause, in the opinion of 66.7% of the participants, the student's perception of a decrease in the quality of their Anatomical formation. Indeed, despite of the benefits reported by the substitute use of on-line and media teaching

This article is protected by copyright. All rights reserved materials (Desai, 2020; Zingaretti et al., 2020) the absence of anatomical dissection is seen by the students as a loss of a crucial part of their development to become a Health professional (Franchi, 2020; Desai, 2020; Srinivasan, 2020) .

The social restrictions to be applied to resume the University courses were not defined in Spain until September 2020. The autonomic (regional) authorities in charge of the administration of the public Universities had not published a definitive decision about the academic year 2020/2021 when the questionnaire was sent, so the Academia main concern was the eventuality of a first semester or a whole academic year to be developed uniquely online. In the event of an online-only resuming of Anatomy teaching, 44.4% of the participants in the questionnaire considered that their Departments had neither enough resources nor a sufficient teaching workforce to ensure a quality teaching, which was in agreement with the reports of Anatomy professors worldwide (Ravi, 2020; Evans et al., 2020) .

Regarding the management of bodies with suspected or confirmed dead from Covid-19, clear indications were published since the pandemic declaration by state administrations (SEAP-IAP, 2020; CDC, 2020; DHHA, 2020) as well as international health authorities (ECDC, 2020; WHO, 2020) and international and national scientific associations and experts (Sañudo, 2015; Kramer et al., 2020; Vázquez-Osorio, 2020; Lemos et al., 2021; Onigbinde et al., 2021) . In a recent review of the different guidelines for the management of cadavers during the pandemics, Dijkhuizen et al (2020) reported that there is no scientific evidence proving that a Covid-19 corpse is still infectious. However, the majority of respondent's institutional authorities applied a complete closure of both the donation services and the research activities in the dissection rooms, a decision not based in solid scientific evidence, but on what World Health Organization (WHO) (Zarocostas, 2020) and Pan American Health Organization (PAHO, 2020) defined as "infodemic" (Sentell et al., 2020) .

Formalin inactivates the SARS-CO-2 virus (Aquila et al., 2020; Pambuccian, 2020) . A recent revision of the safe management of bodies of the pandemic victims (Yaacoub et al., 2020) also reports that a 70% concentration of ethanol, the usual hospital disinfectants and even household detergents, followed by a 0,1% solution of hypochlorite are effective to eliminate the virus (ECDC, 2020). This is

This article is protected by copyright. All rights reserved also the case for the tried-and-true cadaver embalming methods cited in most reports (Balta et al., 2015; Vázquez-Osorio, 2020; Ravi, 2020; Lemos et al., 2021; Onigbinde et al., 2021) . Consequently, the risk in carrying out academic activities directed by experienced academicians working with samples submitted to the usual disinfection, embalming and personal safety procedures employed in the respondent's dissection rooms is limited (Vazquez-Osorio, 2020) . A strict enforcement of the adequate safety protocols and procedures has recently been proposed by Onigbinde et al. (2021) and Lemos et al. (2021) to be applied to resume dissection room activities, including preventive measures proposed by the SAE members and reported in the questionnaire.

All but one DR of the fifteen included in the SAE group were closed for research as well as for teaching activities, with a major impact in numerous projects. It is important to notice how all research projects were forced to stop by the academic authorities, regardless of the specific risk that could represent. No difference was made between research projects including airway or lung manipulations, that could be considered as risky (El-Boghdadly et al., 2020; Onigbinde et al., 2021) and dissections of musculo-skeletal structures or histological investigations on previously embalmed samples, that are free from SARS-CoV-2 (Pambuccian et al., 2020) . This fact contrasts with the numerous guidance papers from scientific societies dedicated to the airway management of in living patients (El-Boghdadly et al., 2020) . Non-aerosol generating procedures in head and neck surgery , otolaryngology (Mick and Murphy, 2020) anesthesia (Herman et al., 2021) or orthopedic surgery (Hirschmann et al., 2020; Basso et al., 2020) , have been carried out in hospitals during the Covid-19 outburst. Moreover, a growing number of papers report using cadavers to simulate aerosol-generating surgical procedures in order to assess the risks and propose recommendations for the practitioner's and patient's protection and safety from SARS-CoV-2 (Workmann et al., 2020; Khoury et al., 2020; Sharma et al., 2020a and b) . Probably a better approach would have been for the academic institutions to face the evidence: formalin and gamma radiation inactivate SARS-CoV-2 (Aquila et al., 2020; Pambuccian, 2020) , so research and teaching activities including bodies treated by these means should have been allowed to continue, adopting extra safety protocols such as the ones proposed by the respondents (reviewing the medical records, refusing the

This article is protected by copyright. All rights reserved potentially contaminated cadavers, and testing, freezing and embalming the accepted ones) and further described by Onigbinde et al. (2021) and Lemos et al. (2021) .

For the management of non-embalmed material, added preventive measures could be implemented, such as polymerase chain reaction (PCR) tests both to the cadaver samples and to the personnel, as well as the compulsory use of disposable personal protective equipment (PPE) and materials, and avoidance of aerosol-generating procedures as defended by Salerno et al. (2020) for autopsies of Covid-19 patients.

The added costs of adopting extraordinary preventive measures, both for research and for teaching activities were the main concern for the participants in the SAE questionnaire. The structural adaptations of the installations (major, 11.1% and minor, 44.4%) that the SAE expert group members considered would be needed, had not been required neither by the institutional (77.8%) nor by the regional (22.2%) authorities responsible both for the donation programs and for the financing of major structural adaptations. Moreover, the majority of the respondents (88.9%) foresaw an increase of the expenses caused by the use of disposable PPEs. Only a 44.4% expected this increased expenditure to be completely covered by their institutions, while a 55.6% assumed that the cost would be at least in part attributed to their respective departments. These budget constraints could be the reason for the institution's almost unanimous decision of suspending the DR activities, as signaled by Ravi (2020) . In a similar manner, the higher costs and complexity of the procedures to manage a cadaver infected by Covid-19 would explain both the total closure of the donation services reported by 44.4% of the participants and the reported 11.1% of refusal of donations of possible Covid-19 deceased patients. This could cause a decrease in the number of cadavers donated in the future, as signaled by both students (Franchi, 2020) and academia Ravi, 2020; Singal et al., 2020, Ooi and Ooi, 2020; Bond and Franchi, 2021) , and would require raising public awareness of the continuing need and the value of the donation for the formation of Health professionals (Brasset et al., 2020) .

In Spain, the bequeathal programs enforced by SAE members constitute a contractual relation between the donor and the Institution that in the future will receive his/her body. The SAE Expert

This article is protected by copyright. All rights reserved Group represents the progress toward more ethical practices than the ones prescribed by the regulations promoted by Hutchinson et al (2019) as a response to the evolution of societal values and needs. However, as reported by the respondents, the pandemic's situation has caused the rejection of body donations under claims of "safety risk" by the institutions. The high cost and complex administrative procedures for funerals are some of the reasons why some people decide to donate their body (Martinez and Brunson, 2019) . Given the fact that the Spanish legal system considers the cadaver a "res extra comercio", the body is to be donated both at no cost and without economic compensation for the donor. Consequently, the relatives of a person whose body donation is rejected will have to face un-planned significant costs and complex administrative procedures. If legal responsibilities are accounted for, it has to be remembered that in Spain the responsibility for the donated bodies relies upon the institution that receives it. So, the person ultimately responsible of it is the Head of the Department, the Dean of the Faculty, the Vice-Chancellor or Chancellor of the University, even if the final disposal of the remains is burial or cremation due to safety restrictions (McHanwell et al., 2008) . Moreover, difficulties for burials and cremations during the lockdown have increased the pandemic`s psychosocial impact (Dubey et al., 2020; Moore et al., 2020) .

The possibility of carrying out specific Covid-19 tests, evoked by 55.6% of the participants, as well as the access to PPEs for both staff and students would cause an increase of the Anatomy department's operating costs. More so, given the fact that 77.8% of the participants reported not to have enough disposable preventive material in stock, due to the donations to the hospitals and critical health services during the height of the pandemics, and the posterior increase of the prizes of those materials.

As mentioned, most of the respondents considered that part (55.6%) or all (11.1%) of the future costs on preventive material were to be covered by the anatomy departments. However, this would result in a clear academic benefit, especially since 55.6% of the SAE expert group members considered that the perception of their students about the quality of the practical anatomic teaching would increase with the awareness created by the adoption of reinforced safety measures. The training in the renewed safety procedures will reinforce the student's competence on prevention (Ross et al., 2021) as well as strengthen non-traditional discipline-independent skills (NTDIS), adaptability and resilience (Evans et al., 2018) .

This article is protected by copyright. All rights reserved Moreover, when, as reported by Bond and Franchi (2021) the teaching of anatomy resumed after the first strict lookout measures were reviewed, it provided, not only anatomical knowledge but life lessons in ethics and humanity (Jones, 2020) , thus addressing the concerns expressed by Pearson (2020) about the risk of missing the formative values the dissection provides to the future health professionals.

The present report is limited by the differences in the regulations applied by each Spanish institution, based on the preventive measures applied in each region during the first months of the pandemics.

Moreover, the questionnaire has revealed a lack of reliable data about the regulatory procedures and the number of body donations at a regional and national level in Spain. Further research will be required to review and actualize the data about body donations in order to sustain the SAE initiative to regulate and improve the donation protocols and procedures,

Despite the perceived risks of the management of cadavers during the pandemics, both the usual embalming procedures and the strict application of all the safety measures for the management of cadavers described in the international and national guidelines, further reviewed during the pandemic outbreak, are adequate to ensure the protection of both students and staff from Covid-19. Dissection is an essential formative activity at all levels of the Health Sciences education, as well as the foundation of morphological research. Its total abandon is not justified by scientific evidence and represents a break of the donor's confidence in the BDPs.

Extra preventive measures, as the implantation of specific tests for the SARS-CoV2, the avoidance of aerosol-generating procedures for non-embalmed cadavers, and the use of disposable protective gear and adequate PPEs could not only increase the security of the staff and students, but also contribute to reinforce their awareness and competences in safety procedures. An evidence-based consensus is required for the adoption of a renewed, comprehensive protocol for present and future donations, as 

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Decreto 2263/1974, de 20 de julio, por el que se aprueba el Reglamento de Policía Sanitaria Mortuoria. Government of Spain, Ministry of Interior

Ley 41/2002, de 14 de noviembre, básica reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación Accepted Article This article is protected by copyright. All rights reserved clínica

Resuming cadaver dissection during a pandemic

COVID-19 and anatomy: Stimulus and initial response

Schools, skills, and learning: The impact of COVID-19 on education. VoxEU-CEPR's Policy Portal

Collection and submission of postmortem specimens from deceased persons with known or suspected COVID-19: Interim guidance

Coefficient alpha and the internal structure of tests

Clinical implications of the COVID-19 pandemic on dental education

Department of Health Hospital Authority. Precautions for Handling and Disposal of Dead Bodies. 10th Ed. Kowloon, Hong Kong: Centre for Health Protection

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Review: The safe handling of a corpse (suspected) with COVID-19

Psychosocial impact of COVID-19

New trends in teaching anatomy and our experience with teaching anatomy in Czech during quarantine regarding COVID-19 pandemic

Risks to healthcare workers following tracheal intubation of patients with COVID-19: A prospective international multicentre cohort study

European Centre for Disease Prevention and Control. Considerations Related to the Safe Handling of Bodies of Deceased Persons with Suspected Or Confirmed COVID-19

Going virtual to support anatomy education: A STOPGAP in the midst of the Covid-19 pandemic

Human skills for human[istic] anatomy: An emphasis on nontraditional discipline-independent skills

Federative International Committee for Ethics and Medical Humanities of the International Federation of Associations of Anatomists (IFAA). Recommendations of good practice for the donation and study of human bodies and tissues for anatomical examination

ICRC Advisory Group on the Management of COVID-19 Related Fatalities. 2020. International Committee of the Red Cross (ICRC): General guidance for the management of the dead related to COVID-19

The impact of the Covid-19 pandemic on current anatomy education and future careers: A student's perspective

Government of India, Ministry of Health and Family Welfare, Directorate General of Health Services (EMR Division

Disruption of anatomy dissection practical in COVID-19 pandemic: Challenges, problems and solutions

COVID-19: Anesthesia management recommendations

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COVID-19 coronavirus: Recommended personal protective equipment for the orthopaedic and trauma surgeon

Can a reliability coefficient be too high?

The law, ethics and body donation: A tale of two bequeathal programs

Impact of COVID-19 on dental education in the United States

Ethical responses to the Covid-19 pandemic: Implications for the ethos and practice of anatomy as a health science discipline

Aerosolized particle reduction: A novel cadaveric model and a negative airway pressure respirator (NAPR) system to protect health care workers from COVID-19

IFAA Best Practice Guidelines for Body Donation Programmes During the Novel Coronavirus Pandemic

Human anatomy education and management of anatomic specimens during and after COVID-19 pandemic: Ethical, legal and biosafety aspects

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Feng Z. 2020. Early transmission dynamics in

Strength, weakness, opportunity, threat (SWOT) analysis of the adaptations to anatomical education in the United Kingdom and Republic of Ireland in Response to the Covid-19 pandemic

China coronavirus: WHO declares international emergency as death toll exceeds 200

Motivations for whole body donation

The legal and ethical framework governing body donation in Europe -A review of current practice and recommendations for good practice

Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: A literature review

Dying, Bereavement and Mortuary and Funerary Practices in the Context of COVID-19

Daily medical education for confined students during COVID-19 pandemic: A simple videoconference solution

The place of cadaveric dissection in post-COVID-19 anatomy education

Impact of SARS-CoV-2 virus pandemic on the future of cadaveric dissection anatomical teaching

Organización Nacional de Trasplantes. Memoria de la actividad de donación y trasplantes. Government of Spain, Ministry of Health

Understanding Infodemic and Misinformation in the Fight Against COVID-19. Factsheet N.5. 1 st Ed

The COVID-19 pandemic: Implications for the cytology laboratory

Forced disruption of anatomy education in Australia and New Zealand: An acute response to the Covid-19 pandemic

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SARS and its effect on medical education in Hong Kong

COVID-19: The immediate response of European academic dental institutions and future implications for dental education

Dead body management in times of Covid-19 and its potential impact on the availability of cadavers for medical education in India

RCPath advice on the opening of fresh or unfixed histopathological specimens during infectious disease outbreaks

Medical student education in the time of COVID-19

Teaching anatomy with dissection in the time of COVID-19 is essential and possible

No autopsies on COVID-19 deaths: A missed opportunity and the lockdown of science

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Facilities and environment of a modern dissecting room

Teaching anatomy at the time of COVID-19

Cadaveric simulation of endoscopic endonasal procedures: Analysis of droplet splatter patterns during the COVID-19 pandemic

On the use, the misuse, and the very limited usefulness of Cronbach's alpha

Cadaverless anatomy: Darkness in the times of pandemic Covid-19

Procedimiento para el manejo de cadáveres de COVID-19. Documento técnico del Ministerio de Sanidad

Medical students' perceptions and an anatomy teacher's personal experience using an e-learning platform for tutorials during the Covid-19 crisis

UK Public General Acts

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Sociedad Anatómica Española, Documento técnico: Manejo de cadáveres COVID 19 (SARS-CoV-2) en los programas de donación de cuerpos para docencia e investigación

Prevención y Control de Infecciones para la Gestión Segura de Cadáveres en el Contexto de la COVID-19, Orientaciones Provisionales, 24 de Marzo de 2020. 1 st Ed

Airborne aerosol generation during endonasal procedures in the era of COVID-19: Risks and recommendations

Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID-19) pandemic: Wuhan and Toronto experience

Safe management of bodies of deceased persons with suspected or confirmed COVID-19: A rapid systematic review

How to fight an infodemic

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