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Covid-19: a puzzle with many missing pieces

BMJ 2020; 368 doi: (Published 19 February 2020) Cite this as: BMJ 2020;368:m627

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Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2)

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Many missing pieces concerning autopsy practice in Italy in COVID-19 era: medico-legal implications

Dear Editor,
The severe acute respiratory syndrome (SARS)-coronavirus-2 (CoV-2) outbreak in Wuhan, China, has now spread to many countries across the world including Italy with over 4000 deaths and more than 47000 infections, as of 20 March 2020. The number of deaths in Italy has now exceeded China.
This will inevitably lead to an increase in the number of suspected coronavirus disease 2019 (COVID-19)-related deaths at autopsy. Although several recommendations and guidelines on autopsy practice relating to COVID-19 have been addressed during the last month, because of the dramatic public health emergency, Forensic departments in Italy are experiencing great difficulties in performing "safe" autopsy, especially those cases ordered by Public Prosecutor nationwide.
In practice, the interest of justice clashes with health security emergencies.
The most serious issue is related to the difficulties and reluctance in performing a preliminary nasal or nasopharyngeal specimens for COVID-19 testing before autopsy. This is because of the huge number of tests ongoing on symptomatic patients. Laboratories are overloaded and have no time to take care of the post-mortem specimens.
Moreover only few hospitals in Italy have dedicated autopsy rooms according to the interim guidance recently issued by Centers for Disease Control and Prevention (CDC).
As a matter of fact there are still many missing pieces also concerning the viral load in post-mortem specimens.
Until novel scientific evidences becomes available, the pathologist should be aware of these critical issues and be extremely cautious in selecting forensic cases for autopsy investigation, making informed the public prosecutors of the serious health risks for doctors.

Competing interests: No competing interests

21 March 2020
Antonio Oliva
Professor of Legal Medicine, MD PhD
Antonio Oliva
Department of Health Surveillance and Bioethics, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italia
Largo Francesco Vito 1, Rome, Italy