Minimally Invasive Autopsy in the Age of the Coronavirus

[Authors: Natalia Rakislova and Adelaida Sarukhan (ISGlobal)]

Just nine months after the first cases were reported in Wuhan (China), COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, has caused more than one million confirmed deaths worldwide. However, experts agree that the real number of direct deaths (those caused by the virus) and indirect deaths (those caused by complications with other diseases or by health system collapse) is actually much higher. Data on excess mortality in 32 countries —i.e. the number of deaths in 2020 above the historical average for the previous five years—indicate that at least 260,000 more people have died during the COVID-19 pandemic than the official figures suggest.

Most people who contract COVID-19 develop only mild or moderate symptoms and may therefore escape diagnosis. Among those who develop severe symptoms or die, the vast majority are older adults (over 65 years of age) or people with chronic health conditions, particularly diabetes, obesity and hypertension. Some, however, are apparently healthy young people. The virus is known to affect not only the lungs but also other organs, either directly or indirectly by triggering an excessive inflammatory response. However, the mechanisms that lead to death after infection are not yet well understood, nor is it certain how many people die from SARS-CoV-2 and how many die from complications with other infections or diseases.

To better understand why some people die of COVID-19 and others do not, post-mortem examinations are necessary. Most COVID-19 autopsies have been performed in high-income countries, while resource-poor countries have had little opportunity to delve into this new field of research

To better understand why some people die of COVID-19 and others do not, post-mortem examinations are necessary. However, complete autopsies require specialised personnel and equipment that are often unavailable in resource-poor countries. In addition, detecting the novel coronavirus requires special biosafety facilities that are not always available, even in high-income countries. Consequently, very few post-mortem examinations have been performed on patients who died of COVID-19 and many questions about the pathology of the disease remain unanswered. Most COVID-19 autopsies have been performed in high-income countries, while resource-poor countries have had little opportunity to delve into this new field of research.

Alternative Technique for Post-mortem Examinations in COVID-19 Cases

This is where the minimally invasive autopsy (MIA) comes in. Over the last few years, we have developed and validated this technique with the aim of determining the causes of death in countries or regions where it is not possible to perform complete autopsies. As the name suggests, the great advantage of MIA is its minimal invasiveness: there is no need to open up the body. MIA can be performed on small tissue samples from various organs and bodily fluids obtained using a long, thin biopsy needle. Consequently, this technique is more easily accepted by the family of the deceased. Moreover, it does not require specialised personnel; any professional trained in the technique can perform MIA. In addition, since the procedure is non-invasive, it minimises the risk of transmitting infectious aerosols, making biosafety facilities unnecessary (slightly upgraded personal protective equipment is sufficient). Finally, our studies have shown that MIA is particularly useful in detecting deaths caused by infectious agents in all age groups (newborns, children, adults and pregnant women).

The great advantage of MIA is its minimal invasiveness: it can be performed on small tissue samples from various organs and bodily fluids

To be sure, MIA has never been used in the context of an epidemic involving a highly transmissible and dangerous emerging pathogen along the lines of, say, the Ebola virus. Furthermore, like any procedure, it does carry some risk. Nevertheless, we have performed hundreds of MIAs on people with HIV and tuberculosis without incident. In the case of SARS-CoV-2, MIA should not pose any additional risk provided that appropriate preventive measures are taken, including the use of straightforward personal protective equipment and meticulous disinfection of surfaces and instruments. Therefore, in light of the risk and the challenges associated with conventional autopsies, MIA may provide a simpler and easier alternative.

We are convinced that widespread use of MIA during the current pandemic is a safe and feasible strategy that could help us obtain a more accurate count of deaths caused by SARS-CoV-2

By way of evidence, autopsies performed during the current pandemic in China and Brazil using a similar non-invasive technique have revealed interesting pathological findings comparable to those of a complete autopsy. Therefore, we are convinced that widespread use of MIA during the current pandemic is a safe and feasible strategy that could help us obtain a more accurate count of deaths caused by SARS-CoV-2 and, more importantly, increase our knowledge about the pathology of COVID-19, particularly in resource-poor countries.