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Covid-19: What is the UK’s testing strategy?

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1222 (Published 26 March 2020) Cite this as: BMJ 2020;368:m1222

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Quick post-mortem coronavirus diagnostic testing,

Dear Editor

One of the biggest problems encountered in the era of the developing COVID-19 pandemic is the lack of clear testing procedures in people suspected of carrying the virus who died before a diagnosis could be reached. It is evident that the number of deaths will increase with the development of the epidemic, and in view of the overloading of hospitals, especially ICUs, selection and prioritizing of patients eligible for hospital treatment is bound to become increasingly popular [1]. Meanwhile, with time, it will become more and more difficult to continue the current trend of large-scale diagnostic testing [2], and hence any tests are and will continue to be primarily intended for living people. The lack of post mortem diagnostics in patients with an unclear serological status therefore becomes the cause of under-reporting on the actual number of patients as well as the deceased. Such data is particularly important due to the fact that reliable and complete statistics of people affected by the COVID-19 allow the state to pursue a preventive policy adequate to the actual threat level. It is worth mentioning that there are already estimates indicating that the factual number of patients and the number of deaths can be significantly higher than the ones officially reported by epidemiological centers around the world [3].

It comes as no surprise that no country conducts extensive post mortem serological studies of people suspected of being infected with SARS-CoV-2. Apart from the economic argument relating to the limited number of tests available, the procedure for the collection of test material is fraught with the risk of infecting healthcare professionals taking the sample, a risk which officials are unlikely to take. In view of the obvious need for prioritizing living patients in the diagnostic process, such decisions can be understood. Nevertheless, in our opinion, such conduct is a mistake that exposes the state to a dangerous underestimation of the threat.

Under normal conditions, in the case of an uncertain cause of death, a traditional autopsy can be ordered. However, in the current situation, conducting an autopsy also carries the risk of contamination, which according to The Royal College of Pathologists may even be on a level playing field with people working in hospital wards [4]. The proposed solution may be posthumous CTs, which undoubtedly entail a lower risk of infection of the investigators, while at the same time being a valuable tool allowing to dispel doubts - with an acceptable margin of error - about the cause of death without the use of scarce and expensive equipment, and without exposing staff to contact with the pathogen. Additionally, it is worth noting that PMCT is a more sensitive diagnostic method in deceased on whom CPR was not performed [5], a situation not difficult to imagine in the current circumstances, especially in the face of widespread patient selection.

Simultaneously, the development of telehealth allows for the rapid consultation of radiologist reports of the deceased in order for the findings to be verified by more than one medical center. The possibility of digitally recording the transmission, serves as a unique opportunity to increase the reliability of such results. However, it should be noted that the extent of lung lesions in the course of viral pneumonia caused by the SARS-CoV-2 is very wide [6], and they may prove difficult to distinguish from the post-mortem lesions that naturally occur in the lungs [7]. In the epidemiological situation in Europe and the US, it seems reasonable to qualify all deceased people who had been previously quarantined and died without a laboratory diagnosis of SARS-CoV-2, as well as non-quarantined individuals who reside in areas with severe transmission of the virus, such as Lombardy, New York or Madrid.

1. https://www.euronews.com/2020/03/12/coronavirus-italy-doctors-forced-to-...
2. https://www.politico.eu/article/europe-testing-question-coronavirus-crisis/
3. David Baud, Xiaolong Qi, Karin Nielsen-Saines et al, Real estimates of mortality following COVID-19 infection, The Lancet Infectious Diseases Mar 17, 2020
4. Briefing on COVID-19 Autopsy practice relating to possible cases of COVID-19 (2019-nCov, novel coronavirus from China 2019/2020). The Royal College of Pathologists, Feb 2020. https://www.rcpath.org/profession/coronavirus-resource-hub.html
5. Sonnemans LJP, Kubat B, Prokop M, Klein WM. Can virtual autopsy with postmortem CT improve clinical diagnosis of cause of death? A retrospective observational cohort study in a Dutch tertiary referral centre. BMJ Open. 2018;8(3):e018834.
6. Chaolin Huang, Yeming Wang, Xingwang Li et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China, The Lancet, Volume 395, Issue 10223, 2020, Pages 497-506, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(20)30183-5.
7. C. O'Donnell, N. Woodford, Post-mortem radiology—a new sub-speciality?, Clinical Radiology, Volume 63, Issue 11, 2008, Pages 1189-1194, ISSN 0009-9260, https://doi.org/10.1016/j.crad.2008.05.008.

Competing interests: No competing interests

30 March 2020
Wojciech Ciepierski
Medical Student
Tomasz Męcik-Kronenberg, Arkadiusz Dziedzic, Bogna Drozdzowska
Department of Pathology, Department of Conservative Dentistry with Endodontics, Medical University of Silesia
3 Maja 13-15, 41-800 Zabrze, Poland, and Plac Akademicki 17, 41-902 Bytom, Poland