key: cord-1004657-usna3ze1 authors: Kritselis, Michael; Remick, Daniel title: Universal precautions provide appropriate protection during autopsies of patients with infectious diseases date: 2020-08-19 journal: Am J Pathol DOI: 10.1016/j.ajpath.2020.08.005 sha: ce0266d0a6e735409bd1db12ab64f3dddb2009f6 doc_id: 1004657 cord_uid: usna3ze1 The current COVID-19 pandemic has raised concerns about the safety of laboratory personnel who handle tissue samples that harbor pathogens, including performing autopsies. While pathologists have performed autopsies on infected patients for centuries, universal precaution protocols to limit exposure to pathogens were not developed until the 20(th) century. This paper reviews the history and effectiveness of universal precautions, with an emphasis on performing autopsies on COVID-19 patients. The current COVID-19 pandemic has raised concerns about the safety of laboratory personnel who handle tissue samples that harbor pathogens, including performing autopsies. While pathologists have performed autopsies on infected patients for centuries, universal precaution protocols to limit exposure to pathogens were not developed until the 20 th century. This paper reviews the history and effectiveness of universal precautions, with an emphasis on performing autopsies on COVID-19 patients. The Acquired Immune Deficiency Syndrome (AIDS) epidemic in the 1980s caused a significant change in the delivery of healthcare, specifically gloves and gowns are now worn much more frequently. These changes essentially became the new normal and it is unlikely that a healthcare worker will examine a patients or handle a biological specimens without gloves. Initially a clear etiology for AIDS was not determined, therefore, the Center for Disease Control (CDC) published precautions for clinical and laboratory staffs in November, 1982 1 . Confirmation that transmission of the human immunodeficiency virus (HIV) caused AIDS did not occur until later 2 . Since the etiology of AIDS was not initially known, it was not possible to test for the presence of the virus or antibodies to the virus. Consequently, the concept of universal precautions was developed where all biological specimens should be considered potentially infectious and precautions were recommended that should be followed universally. These precautions included wearing gloves when handling blood specimens or other body fluids, wearing gowns and hand washing. After HIV was determined to cause AIDS it was found that the virus could be isolated from several bodily fluids including blood, semen, saliva, tears etc. and it was J o u r n a l P r e -p r o o f recognized that healthcare workers were at increased risk of infection when providing care for these patients. The initial universal precautions guidelines have been updated several times, emphasizing ". . . the need to treat blood and other body fluids from ALL patients as potentially infective" 3 . While infectious diseases have always been present in pathology samples, the AIDS epidemic increased awareness of the need for robust safety protocols. Universal precautions were widely adopted including the use of cut resistant gloves, which significantly decrease hand injuries 4 . The importance of using universal precautions was highlighted in one small study where two cases with no known risk factors were found to be positive for HIV at autopsy 5 . The exposure to other infectious diseases, such as hepatitis, is even greater than the potential transmission of HIV 6 . This emphasizes the need to use universal precautions for all autopsies, not just those known to be potentially infectious. The importance of using universal precautions during the COVID-19 pandemic needs to be reinforced. The concept of healthcare workers wearing personal protective equipment (PPE) frequently appears in the lay press during the 2020 COVID-19 pandemic, even when collecting nasopharyngeal swabs. Another culprit for autopsy-related infections includes tuberculosis. Cases of people obtaining tuberculosis (TB) during autopsies have been documented since the 18th century and continues to occur 7 . Compared to the general population, the occupational risk for developing TB for laboratory and postmortem room staff is estimated to be 100-200 times greater 8 . While the incidence of TB being present at autopsy has decreased due to the lower worldwide prevalence of the disease, it is still a hazard and highlights the need for universal precautions. Other bacterial infections may cause morbidity and mortality at the autopsy. There have been reports of medical students and physicians acquiring Streptococcus pyogenes infections following J o u r n a l P r e -p r o o f superficial injuries 9 . Hepatitis B viral (HBV) infection is a highly infectious illness primarily transmitted through percutaneous or mucosal exposure to infected blood or other bodily fluids. Transmission may occur perinatally, sexually, and parenterally. Prior to the availability of a vaccine in 1982, an estimated 200,000-300,000 persons in the US were infected annually with hepatitis B 10 . After the vaccine became available, mandatory screening of pregnant women for the presence of the hepatitis B surface Antigen (HBsAg) and universal vaccination of newborns was implemented in the 1990s resulting in a 10 fold reduction in HBV infections. The peak incidence of reported acute HBV infection was 11.5 per 100,000 in 1985 11 . Following updated vaccine and testing protocols, the incidence has steadily declined to 0.9 per 100,000 in 2014 12 . It should be noted that even with the decrease in the overall incidence, the prevalence and incidence of hepatitis B infection among health care workers is much higher than the general population, with pathologists and laboratory technicians being among those with the highest risk of infection 13 . For healthcare workers, the CDC recommends vaccination, followed by anti-HBs serologic testing 1-2 months after the final dose. Vaccination should be done in any healthcare worker lacking documented evidence of a complete hepatitis B vaccine series, or those who lack an upto-date blood test that shows immunity 10 diagnosis. However, caution must be followed since the agents that cause Creutzfield-Jakob disease are highly resistant to disinfection protocols and even tissue from paraffin-embedded blocks can cause disease. Current World Health Organization (WHO) guidelines advocate the use of proper PPE as well as the limitation of aerosol production. The use of electric saws are discouraged unless appropriate protocols are followed 14 . Limiting bone sawing has been suggested since both human and veterinary autopsy procedures generate aerosols 15, 16 . Despite these concerns, appropriate protocols, such as the use of purified air powered respirators and placing the head inside a transparent plastic bag, provide protection from personnel in the autopsy suite. After the outbreak of "mad cow disease" in England, several countries initiated surveillance programs by performing brain autopsies in suspected cases. The reports of these programs do not mention any transmission to autopsy personnel 17, 18 . A French study also did not show any transfusion associated cases, showing that the transmissibility is low 19 . Of course the current SARS-CoV2 is predominantly a respiratory pathogen so comparisons The original SARS-CoV virus has been found in multiple tissues at autopsy, although the J o u r n a l P r e -p r o o f highest concentrations were in the lungs and small bowel 22 . 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