Forensic pathologists beware: COVID-19 lives on in blood after death

‘It is more resilient in that it sticks around the dead body’: California’s Dr. Judy Melinek develops protocols for limiting exposure of medical staff to virus during autopsies

Renee Ghert-Zand is the health reporter and a feature writer for The Times of Israel.

Dr. Judy Melinek (left) and colleague in their PPEs, including PAPR for Melinek. (Twitter)
Dr. Judy Melinek (left) and colleague in their PPEs, including PAPR for Melinek. (Twitter)

Dr. Judy Melinek, a forensic pathologist in the San Francisco Bay Area, has performed autopsies under many different circumstances. The current COVID-19 pandemic, however, poses new challenges in terms of protecting herself and her colleagues and limiting the spread of the deadly virus.

“We are used to dealing with contagious pathogens like tuberculosis, hepatitis and HIV. COVID-19 is different only in that there is currently no treatment… and it is more resilient in that it sticks around the dead body after death,” Melinek recently told The Times of Israel.

While populations are being told to practice social distancing — to keep two meters away from other people to avoid transmitting the virus by coughing or sneezing — Melinek and her colleagues at the Alameda County Sheriff Coroner’s Office in Oakland, California, have additional means of infection to contend with.

Dr. Judy Melinek (Doug Zimmerman)

“[COVID-19] is a respiratory pathogen and can be transmitted via respiratory droplets, but also through the blood of a viremic patient. Even though decedents don’t cough, they can expel bodily fluids while they are being moved or transported,” she explained.

The granddaughter of Holocaust survivors, Melinek was born in Israel and moved to the United States with her parents at age five. She has been qualified as an expert witness in forensic pathology, neuropathology and wound interpretation. Together with her husband T.J. Mitchell, she has written two books for general audiences: a memoir titled “Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner,” and a recently published novel, “First Cut.” Melinek is a contract pathologist for the Alameda County Sheriff Coroner, and notes that she does not speak for the agency, and her statements and opinions are her own.

Melinek said that so far the coronavirus outbreak has not significantly increased her workload, but expects this could change.

She and her colleagues at the coroner’s office will not perform autopsies on bodies in instances where the hospital physician who treated the patient can certify that the cause of death was COVID-19 and writes the death certificate.

“The coroner’s office only gets involved if the death is sudden, unexpected, or violent. So if someone dies at home, our deputies will be notified, but again, if the decedent has a doctor who can certify that the death was from the coronavirus infection, then the decedent would not need an autopsy,” Melinek said.

If a person dies with “flu-like” symptoms, then the sheriff-coroner’s office deputies ask questions at the death scene to establish if the patient traveled recently, and whether they were exposed to a known COVID-19 positive patient.

“A nasopharyngeal swab can be done on the first day and if it comes back positive, we may be able to certify the death without an autopsy, just based on the clinical history of respiratory distress and the positive viral test,” Melinek said.

She added that the Occupational Safety and Health Administration (OSHA) currently does not recommend performing an autopsy in COVID-19 positive patients for diagnosis.

Dr. Judy Melinek in her forensic pathology lab (Leah Mitchell)

In cases where the test is negative, Melinek and her associates may need to perform an autopsy to figure out what other natural disease was the cause of the decedent’s symptoms. In those cases, she may take microscopic sections of the lungs, heart and upper airways to look for disease.

As the numbers of those who become infected, sicken and die from coronavirus increase, Melinek and fellow forensic pathologists will still continue to follow their legal mandate to investigate and determine the cause and manner of death in cases in which deaths are unexpected, sudden or violent — such as homicide, suicide, accident, heart attack, stroke, and drug overdose.

However, during this pandemic, it will be anything but work as usual for Melinek. A routine case, such as a murder, could be impacted by the community spread of COVID-19. A person could have died a violent or unexpected death, but that does not exclude them from being coronavirus-positive and asymptomatic before dying.

“As COVID-19 spreads throughout the community… we want to keep our staff safe so that they don’t expose themselves and others to the disease. It means we need to use proper personal protective equipment (PPEs) and monitor our staff for illness,” Melinek said.

According to Melinek, standard personal protective equipment for an autopsy is an N95 respirator, face shield, booties, plastic apron, hair net, and double gloves. In the past she and her associates would use surgical masks, but now they are using N95s in all their cases.

Forensic pathologists are currently also using powered air-purifying respirators (PAPRs), disposable hoods that attach to a hose and pump that creates positive pressure within the hood and filters the air they breathe. Reusable hoods also exist, which have to be decontaminated between cases.

Dr. Judy Melinek showing her PAPR from behind. (Twitter)

Asked whether there was enough such protective equipment available locally, nationally and internationally, Melinek said, “Every coroner and medical examiner nationwide is currently inventorying their supplies, ordering as needed, and writing protocols that will conserve what they have.”

She explained how scheduling changes can conserve PPEs. “Three doctors with three technicians performing three autopsies at the same time utilizes six masks. But if one doctor performs all three autopsies with one tech they use only two masks,” she said.

Another way forensic pathologists are trying to minimize their exposure to the coronavirus is by limited dissections targeted at getting to a diagnosis when doing an autopsy on a COVID-19 positive case. The fewer cuts into the corpse, the better.

Melinek has been helping her colleagues around the world develop and share these protective protocols.

“There have already been several articles published in the peer-reviewed literature on the subject coming out of China, but informally we share our immediate findings over email via the National Association of Medical Examiners email list. I created a Dropbox of autopsy and death investigation protocols from around the world and we have been sharing that as well. That way pathologists have an easy template to work with from offices of similar size, and they don’t have to start from scratch to write a protocol for their office,” Melinek said.

Melinek and her colleagues are practicing social distancing at their workplace and adapting their PPE practices to the current pandemic. She implores people to stay at home, wash their hands, and social distance if they have to go out for food or medical care.

“In time, we may be more at risk of catching coronavirus from going to the supermarket than from going to work in the morgue,” she said.

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