Infectious Diseases and the Autopsy
- 1Department of Pathology and Laboratory Services, Denver Health Medical Center, Denver, Colorado
- 2Department of Pathology, University of Colorado School of Medicine, Denver, Colorado
- Reprints or correspondence: Dr. Michael L. Wilson, Dept. of Pathology and Laboratory Services, Mail Code #0224, Denver Health Medical Center, 777 Bannock St., Denver, CO 80204-4507 (michael.wilson{at}dhha.org).
Despite decreasing autopsy rates in many parts of the world, the autopsy retains its value for determining the cause of death, for detecting clinically unknown lesions, as a quality assurance tool, and for providing accurate information for death certification [1–12]. The most recent published data regarding the usefulness of the autopsy indicate that 20%–30% of patients who die in hospitals have important diseases/lesions that are undetected before death but that are found at autopsy [1–7]. This is true for both adult and pediatric patients [7]. For infectious diseases, the data are the same: a substantial number of infections are undetected before death but are detected by postmortem examination [9–12]. In this issue, Paul and Jacob [13] report an outbreak of chickenpox among 4 of 22 health care workers present during the autopsy of a patient who died of probable disseminated varicella-zoster virus. This report highlights a number of issues regarding the role of the autopsy in the diagnosis of infectious diseases.
In the United States, many pathologists receive certification in both anatomical and clinical pathology; however, because of the way pathologists and clinical laboratories are paid for their services, most practicing American pathologists must focus their efforts on anatomical pathology—particularly surgical pathology and cytopathology. Moreover, few pathologists practicing today have the time to maintain expertise in disciplines beyond surgical pathology and cytopathology, which are very demanding. In addition, the nature and quality of training in subspecialties such as medical microbiology varies substantially between training programs. Thus, for many American pathologists, the theoretical benefits of a residency that combines both anatomical and clinical pathology training are lost because of the way that pathology is practiced in our current health care system. Moreover, because of decreasing autopsy rates, many pathologists do not have the expertise in autopsy pathology that once was common. Taken together, the current situation is obviously not ideal for a modern hospital-based autopsy practice and, in particular, for the performance of autopsies related to infectious diseases. As I noted in a recent editorial, organized pathology in America needs to pay more attention to infectious disease pathology [14].
Because of decreasing autopsy rates and the fact that autopsies are not paid for by the government or by private insurers, it should come as no surprise that many hospital autopsy facilities are woefully out of date and inadequate for the purpose of modern autopsy practices. This is particularly true for autopsies performed on patients with infectious diseases, for whom a safe autopsy requires a facility that can be effectively decontaminated and that has adequate ventilation and air handling systems, controlled access, and other design features [15]. Although many community hospitals may not have the types of patients necessitating such facilities, it is not unreasonable to expect this type of facility investment at medical examiners' offices, academic medical centers, and large urban public hospitals. As an aside, of the billions of dollars spent on defense against bioterrorism, little appears to be earmarked for autopsy facilities—sites likely to be on the front lines of bioterrorism and emerging infectious diseases.
There were many lapses in infection control in Paul and Jacob's [13] reported case. Although it may be tempting to dismiss this report as a mere summary of inadequate infection-control practices, there were a number of factors that precluded or contributed to adequate infection control. First, there were far too many persons in the morgue during the procedure for adequate teaching or supervision. The safety of everyone in the morgue during an autopsy is the responsibility of the attending pathologist—there is no way that one person can teach or supervise another 21 persons. For autopsies on patients with communicable diseases, it is generally recommended that a minimum number of persons directly involved with the case be present until the case is finished and the tissue is fixed in formalin. Although this practice may preclude some teaching opportunities, much of the teaching can occur after the fact because organs and tissues do not change that much in appearance after a day or 2 in formalin. Second, the personal protective equipment used during the autopsy in this case was inadequate because there was the potential for exposure to skin via splash. The purchase and use of adequate personal protective equipment is expensive, but limiting the number of persons present for an autopsy can both mitigate the cost of personal protective equipment as well as improve the ability of the attending pathologist to make certain that personal protective equipment is used appropriately. Third, there was insufficient knowledge as to the immune status of those present during the autopsy. Collecting and acting upon this information is the responsibility of the hospital and, in the case of students, the medical school. Last, this group of students did not heed the advice to stay away from the autopsy table in order to prevent exposure during splashes. Again, it is difficult or impossible for the attending pathologist to keep track of this number of students; compliance would have been much easier to maintain with fewer or no students present. It can be difficult to balance the needs of students and trainees against other factors, but one should never compromise safety or quality.
In closing, this case highlights a number of obvious lapses in infection-control procedures and in circumstances leading to those lapses. Although the autopsy remains a valuable diagnostic and teaching tool, to be safe—for infectious diseases in particular—it requires adequate training of pathologists, proper use of personal protective equipment, adequate facilities, and careful adherence to infection-control practices. What can infectious diseases practitioners do about all this? First, they can help improve autopsy rates by working with families to emphasize the usefulness of the autopsy. Second, they can work with pathologists to improve compliance with infection-control practices in autopsy facilities, which may alleviate some of the discomfort and uncertainty many pathologists have in performing autopsies on patients with infectious diseases. Third, they can help persuade hospital administrators of the need for robust, modern autopsy practices within their hospitals, which may require investment in facilities and other infrastructure. Last, they can help provide the information that pathologists need to integrate the clinical, radiographic, and laboratory findings with the results of postmortem examinations. Modern patient care is a multidisciplinary effort, and modern autopsy practice should be no different.
- Received June 6, 2006.
- Accepted June 6, 2006.
- © 2006 by the Infectious Diseases Society of America
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