Humandissection has long been the ‘gold standard’ for teaching and research in the anatomical sciences. Anatomistsrely on the altruism of individuals to donate their bodies so that healthsciences professionals in training can continue to be privileged byexperiencing the structural details of the human body. We thus continue to beextremely grateful to those individuals who donate their bodies. For theprocess of body donation to be accepted by the donors and the public, it isimperative that high ethical standards prevail. Under these conditions,numerous body donor programmes have been achieved around the world. The bestpractice guidelines of the IFAA ( ) present recommendations for theethical sourcing and use of human bodies.

Duringoutbreaks of infectious diseases, the sourcing of bodies and continuance ofdonor programmes comes under stress. Numerous guidelines have been produced byorganisations and governments during the present novel coronavirus pandemic,which will be of great use to anatomists who facilitate donor programmes. TheIFAA has summarised current information on important aspects of the handling ofbodies during the coronavirus pandemic in order to provide information to itsconstituent members. It stresses the importance of scientific evidence, whichshould be the guiding principle wherever available.

Thefollowing refers to the handling of the dead body in the context of anatomy. Asfor the contact of staff with living donors and/or with donors' family members,the general safety rules regarding possible Covid-19 infection apply. It isrecommended that all such contact is made via telephone, mail or internet forthe time being. Whether the general activities of running of a body donationprogramme should be suspended depends on the local situation and the guidelinesof the local authorities regarding workplace safety in times of the pandemic.

The COVID-19virus is mainly transmitted through large respiratory droplets by inhalation orcontact with mucosal surfaces, but other modes of transmission have beensuggested (airborne, faeco-oral, contact with contaminated surfaces). There isno evidence so far that the virus is transmitted through contact with the skinof a deceased person, but as the virus is known to persist on surfaces forhours or days, depending on the nature of the surface (Kampf et al., 2020),this mode of transition cannot be ruled out. The risk of transmission likelyincreases with direct contact with bodily fluids, and certainly increases withinvasive handling of the cadaver, as in autopsy procedures, if it producesdroplets or aerosols (ECDC 2020a, Finegan 2020).

The following are of particular importance for anatomists withbody donor programmes:

· No evidence has been found so far of individuals who have become infectedfrom exposure to the bodies of persons who have died from COVID-19 (WHO 2020b).

· In general, the "potential risk of transmission related to thehandling of bodies of deceased persons with suspected or confirmed COVID-19 isconsidered low" (ECDC 2020a).

· While there is no evidence yet that the COVID-19 virus isspecifically inactivated in a preserved body donor, the commonly usedpreservatives, formaldehyde and ethanol, appear to be efficient against thevirus (Shidham et al., 2020).

Safety and well being of staff

· In general, the safety precautions applied in the basic handling ofany human cadaver should cover the risk of a Covid-19 infection. As in anygiven case, if no infection (including HIV, Tbc) can be confidently ruled out,any cadaver should be treated as potentially infectious. In the absence of atest for COVID-19, this also applies to the risk of a COVID-19 infection.Suitable precautions are recommended based on the nature of the task to beundertaken (see below).

· All staff responsible for the collection, transportation andpreparation of bodies infected, or suspected of being infected, with COVID-19,must be trained specifically for their tasks, including the use of personalprotective equipment (PPE). (For further details on PPE see CDCP, 2019a).

· The safety and health of those individuals handling the unembalmedbody (mortuary staff, other personnel) should be the most important priority.Managers should thus ensure that the necessary PPE supplies are available tothose staff responsible for accepting, collecting, transporting and preparingof the bodies.

· Mortuary staff and personnel who are responsible for thecollection, transportation and preparation of bodies must use appropriate PPE.Minimum requirement for any handling of the body includes an impermeabledisposable gown [or disposable gown with impermeable apron], gloves and faceprotection such as goggles and a fluid-resistant medical mask (Finegan et al.2020, WHO 2020b). A long-sleeved water-resistant gown is recommended by theECDC (2020a). Adequate ventilation of laboratories where bodies are handled isalso important. Finegan et al. (2020, pages 4 and 5) supply detailed technicalinformation for those staff who will be handling bodies.

· It is recommended that with any significant manual handling of thebody, an FFP2 or FFP3 mask should be worn in addition to the above (Finegan etal. 2020, RCP 2020b)

· If at all possible, any invasive procedures on the unembalmed body(as in standard pathology autopsies) should be avoided. In particular, this includesprocedures generating aerosols, like use of an oscillating saw. If suchprocedures are necessary, full protection with PPE including a FFP3 mask isnecessary (Finegan et al. 2020, RCP 2020b).

· Appropriate PPE should also be supplied to cleaning and wastemanagement staff (ECDC, 2020a).

· Mortuary staff must be trained in, and apply, standard precautionsfor hand hygiene (for further details on hand hygiene see CDCP, 2019a) and thepossible inclusion of shower facilities for those staff handling the embalmingof bodies.

Surface decontamination

The humancoronaviruses is said to remain infectious on surfaces for up to 9 days (Kampfet al., 2020). Under experimental conditions, the COVID-19 virus has beendetected after up to 72 hours following application to certain surfaces (vanDoremalen, 2020). Therefore, cleaning of the environment exposed toCOVID-19-infected bodies is crucial.

· It is not presently known whether a route of infection for COVID-19is from the skin surface (RCP, 2020a)

· The ECDC (2020a) recommend regular cleaning followed bydisinfection of all surfaces with hospital disinfectants. Should hospitaldisinfectants not be available then the use of a decontaminant such as 0.1%sodium hypochlorite (dilution 1:50 if household bleach at an initialconcentration of 5% is used) or 70% ethanol is suggested. Prior to the use ofthe decontaminant, a neutral detergent should be used. However, currently thereis no information available on the effectiveness of this approach [EDCD,2020b).

· All waste should be treated as infectious clinical waste Category B(WHO, 2012).

Transportation of bodies

· While body bags are said not to be necessary for transportation(WHO 2020b), they should be used in case of body fluid leakage (WHO 2020b).However, the ECDC (2020) and the NSW Health (2020) recommend the use of twobody bags (double-bagging). Possible contamination of the outside of the bagshould be managed by decontamination procedures.

· Transport equipment and vehicles can be of the standard type (WHO,2012; WHO, 2020b) but decontamination after use should be ensured.

Embalming of bodies infected with the novel coronavirus

Embalming ofbodies infected by the novel coronavirus is not recommended by the WHO (2020b)but this is in the context of advice for funeral homes. In the case of anatomydepartments, embalming cannot be avoided. The reason provided by the WHO(2020b) and the NSW Health authority for not recommending embalming is in orderto minimize manipulation of the body and thus the possible generation ofaerosol. The Department of Health of South Africa (2020) asserts that embalmingof a body infected with the novel coronavirus does not pose a risk. However,forced inflation of the lungs, which may occur during fixation, may generateaerosol (RCP, 2020b). Thus any aerosol generating procedures and splashes ofcontaminated fluids should be avoided during embalming. The use of PPE asdescribed above applies during all embalming procedures.

Protocolsused for histopathology “have almost always been effective ininactivating a broad range of viruses, even Ebola” (Rossi et al. 2020). The same is true for most standard embalming proceduresused in gross anatomy (Demiryürek et al. 2002). Aseries of studies have demonstrated that formalin and glutaraldehyde are ableto inactivate SARS-CoV in a temperature-dependent and time dependent manner(Darnell, 2004; Henwood 2018 ; Kampf et al 2020; Xu et al., 2020). As thestandard embalming procedures with these chemicals have been safe for all otherinfective agents (except prions) in the past, it is therefore relatively safeto assume that a standard embalming procedure with formalin and/or ethanolinactivates the COVID-19 virus. Extended periods of fixation in formalin arerecommended for tissues for histology (Rossi et al., 2020). Whether extendedperiods of preservation before use of bodies fixed in formalin for dissectionshould be recommended for bodies carrying the COVID-19 virus will need furtherevidence.

The IFAArecommends adhering to the guidelines produced by various organisations such asthe WHO (2014; 2020a,b); Finegan et al., 2020 (for the International Committeeof the Red Cross), ECDC (2020a, b) and the New South Wales Health authority(2020). Regular updates to this document are welcome from anatomists andAnatomical Associations.

While theseGuidelines have been produced in good faith for anatomists who wish to continuetheir dissection programmes during the pandemic, the IFAA cannot attest to thecompleteness, reliability or accuracy of the information supplied in thisdocument. Any action taken in relation to these guidelines is at your own riskand the IFAA is not responsible for any negative outcomes.

Contributors to the Guidelines: BeverleyKramer, Brendon Billings, Bernard Moxham and Andreas Winkelmann

References:

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