* The following is a summary of guidance from the U.S Centers for Disease Control and Prevention and other agencies and organizations distributed in published resources cited at the bottom of this page. Please consult these resources directly using the provided links for additional details and guidance updates. This summary was last updated on May 7, 2020.

When to conduct postmortem evaluation(s) for COVID-19¹

Use your judgment to determine if a decedent had signs and symptoms compatible with COVID-19 prior to death and whether postmortem testing should be pursued. Most patients with COVID-19 develop fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).2 There are epidemiologic factors that may also help guide decisions about testing for COVID-19 including documented cases of COVID-19 in the jurisdiction where the decedent lived or worked, known community transmission in that jurisdiction, contact between the decedent and a person known to or suspected of having COVID-19, or association of the decedent with a cluster of respiratory illness in a closed setting (e.g., long-term care facility). Even when COVID-19 is suspected, additional examination and testing for other causes of respiratory illness (e.g., influenza) is strongly encouraged.

Additionally, DHEC is requesting that COVID-19 testing be performed on any decedent that died at home or unexpectedly without another cause of death, even if evidence or suspicion of COVID-19 is lacking.

What information on COVID-19 to request prior to an examination¹

You may request that facilities provide the following in addition to normal reporting demographics and information:

1. Did the decedent ever test positive for COVID-19?
2. Did the decedent exhibit symptoms consistent with COVID-19 and receive a test for COVID-19 for which the results are still pending?
3. Did the decedent exhibit symptoms consistent with COVID-19 upon screening?
   • Symptoms typically include one or more of the following: cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell.²
4. Was the decedent known to have been a contact of or exposed to one or more persons who ever tested positive for COVID-19?

How to proceed with an examination if the decedent was a known or suspected COVID-19 case¹

Current knowledge suggests that disease transmission occurs primarily through inhalation of airborne droplets containing virus produced when an infected person coughs, sneezes, or talks.

Postmortem activities should be conducted with a focus on avoiding aerosol generating procedures and ensuring that if aerosol generation is likely (e.g., when using an oscillating saw) that appropriate engineering controls and personal protective equipment (PPE) are used. 

Use standard precautions and appropriate work practices to guard against direct contact with infectious materials, percutaneous injury, and hazards related to moving heavy remains and handling embalming chemicals. 

Recommended collection of postmortem specimens¹

It is recommended that the following specimens be collected under the specified circumstances:

Decedent is a suspected COVID-19 case, autopsy NOT performed

• Postmortem nasopharyngeal swab (NP swab) specimen for COVID-19 testing.
• Separate NP swab for testing of other respiratory pathogens.

Decedent is a suspected COVID-19 case, autopsy performed

• Postmortem swab specimens for COVID-19 testing including from the upper respiratory tract (nasopharyngeal swab (NP swab)) and lower respiratory tract (lung swab from each lung).
• Separate swab specimens for testing of other respiratory pathogens and other postmortem testing, as indicated.
• Formalin-fixed autopsy tissues from lung, upper airway, and other major organs.

Decedent is a confirmed COVID-19 case, autopsy performed

• Postmortem swab specimens for testing of other respiratory pathogens.
• Other postmortem microbiologic and infectious disease testing, as indicated.
• Formalin-fixed autopsy tissues from lung, upper airway, and other major organs.

Additional and more detailed information about specimen collection, processing, preservation, and preparation for shipping is provided in the source material.¹

Methodological notes for collection of postmortem specimens¹

When collecting upper respiratory tract swab specimens

Nasopharyngeal (NP) specimen is the preferred choice for upper respiratory tract swab-based SARS-CoV-2 testing. When collection of a postmortem NP swab is not possible, each of the following is an acceptable alternative:

• An oropharyngeal (OP) specimen
• A nasal mid-turbinate (NMT) swab
• An anterior nares (nasal swab; NS) specimen, nasopharyngeal wash/aspirate or nasal aspirate (NA) specimen

Insert flexible wire shaft minitip swab through the nares parallel to the palate (not upwards) until resistance is encountered or the distance is equivalent to that from the ear to the nostril of the patient, indicating contact with the nasopharynx. Swab should reach depth equal to distance from nostrils to outer opening of the ear. Gently rub and roll the swab. Leave swab in place for several seconds to absorb secretions. Slowly remove swab while rotating it.

• Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing. For nasal swabs (NS), a single polyester swab with a plastic shaft should be used to sample both nares.
• Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media.
• Nasal swabs (NS) or nasal mid-turbinate (NMT) swabs should be placed in a transport tube containing either viral transport medium, Amies transport medium, or sterile saline.
• If both NP and OP swabs are collected, they should be combined in a single tube to maximize test sensitivity and limit use of testing resources.

When collecting lower respiratory tract swab specimens

• Collect one swab from each lung (left and right). Options for lung swab collection include the following, and may depend on the institution’s standard practices or type of autopsy procedure (e.g., full or in-situ autopsy)
  • During the internal exam, after the heart-lung block is removed, insert one swab as far down into the tracheobronchial tree as possible on either side (left and right), or
  • First wipe the surface of each lung with an iodine-containing disinfectant clean and dry the surface; then use a sterile scalpel to cut a slit of the lung and insert the swab to collect sample on either side.

Storage of swab specimens

• Store specimens at 2-8°C for up to 72 hours after collection. If a delay in testing or shipping is expected, store specimens at -70°C or below.

When collecting autopsy tissue specimens

CDC recommends collection of

• Minimum of 3 representative sections of lung parenchyma, preferably from different locations, and
• Minimum of 2 sections of airway, to include trachea, bronchi, or both airways.
• To minimize potential viral contamination of non-involved tissues, lung and airway specimens should be collected immediately following removal of the chest plate. Then place specimens into a separate sterile specimen cup containing 10% neutral buffered formalin.
• Collection of tissue samples approximately 5 mm in thickness (i.e., sample would fit in a tissue cassette) is recommended for optimal fixation.
• Tissues should be placed in 10% buffered formalin, in a volume that is approximately 10 times greater than the volume of tissue.
• Optimal fixation is three days (72 hours). Specimens should be shipped as soon as possible following complete fixation. Prolonged immersion in formalin (e.g., > 2 weeks) can diminish the sensitivity of virus detection assays.
• If involvement of one or more other organs (e.g., heart, kidneys) is suggested by clinical history or laboratory findings obtained prior to death, representative samples of these tissues should be considered for sampling and submission.

Additional and more detailed information about specimen collection, processing, preservation, and preparation for shipping is provided in the source material.¹

Serological testing¹

At the time this guidance document was last updated, antibody tests had not been validated for diagnosis of COVID-19 infection and were of limited value in the immediate diagnosis of a patient where COVID-19 was suspected. In the future, if/when antibody tests become a more reliable and widely used tool for diagnosing exposure to or infection by SARS-CoV-2, serological testing of decedents may be warranted. Consult the source material1 for additional and more up-to-date information and recommendations regarding serological testing.

Recommended engineering controls and PPE during examination and specimen collection¹

It is recommended that the examination and specimen collection be performed using the following engineering controls and PPE under the specified circumstances:

Decedent is a confirmed or suspected COVID-19 case, autopsy NOT performed, ONLY nasopharyngeal swab (NP swab) specimens collected

• Follow standard precautions.
• Recommended PPE:
  • Nonsterile, nitrile gloves when handling potentially infectious materials.
  • Heavy-duty gloves over the nitrile gloves if there is a risk of cuts, puncture wounds, or other injuries that break the skin.
  • A clean, long-sleeved fluid-resistant or impermeable gown to protect skin and clothing.
  • A plastic face shield or a face mask and goggles to protect the face, eyes, nose, and mouth from splashes of potentially infectious bodily fluids.
• A NIOSH-certified disposable N-95 respirator or higher is NOT required.
  • If the PPE supply is low, see Strategies for Optimizing the Supply of PPE.³
• Setting: A negative pressure room is NOT required.
• Individuals in the room during specimen collection should be limited to the healthcare personnel (HCP) obtaining the specimen.
   

Decedent is a confirmed or suspected COVID-19 case, autopsy performed or aerosol generating procedures (AGPs) are being conducted

• Follow standard precautions, contact precautions, and airborne precautions with eye protection.
• Recommended PPE:
  • Double surgical gloves interposed with a layer of cut-proof synthetic mesh gloves.
  • Fluid-resistant or impermeable gown.
  • Waterproof apron.
  • Goggles or face shield.
  • NIOSH-certified disposable N-95 respirator or higher. Powered, air-purifying respirators (PAPRs) with HEPA filters may provide increased worker comfort during extended autopsy procedures.
  • Surgical scrubs, shoe covers, and surgical cap should be used per routine protocols.
  • If the PPE supply is low, see Strategies for Optimizing the Supply of PPE.³
• Setting: autopsies should be conducted in Airborne Infection Isolation Rooms (AIIRs). These rooms are at negative pressure to surrounding areas, have a minimum of 6 air changes per hour (ACH) for existing structures and 12 ACH for renovated or new structures, and have air exhausted directly outside or through a HEPA filter. Doors to the room should be kept closed except during entry and egress. If an AIIR is not available, ensure the room is negative pressure with no air recirculation to adjacent spaces. A portable HEPA recirculation unit could be placed in the room to provide further reduction in aerosols.
• Aerosol generating procedures (AGP) such as use of an oscillating bone saw should be avoided for known or suspected COVID-19 cases. Consider using hand shears as an alternative cutting tool. If an oscillating saw is used, attach a vacuum shroud to contain aerosols.
• Allow only one person to cut at a given time.
• Limit the number of personnel working in the autopsy suite at any given time to the minimum number of people necessary to safely conduct the autopsy.
• Limit the number of personnel working on the human body at any given time.
• Use a biosafety cabinet for the handling and examination of smaller specimens and other containment equipment whenever possible.
• Use caution when handling needles or other sharps, and dispose of contaminated sharps in puncture-proof, labeled, closable sharps containers.
• A logbook including names, dates, and activities of all workers participating in the postmortem and cleaning of the autopsy suite should be kept to assist in future follow up, if necessary. Include custodian staff entering after hours or during the day. 

Recommended cleaning and handling procedures following examination and specimen collection¹

SARS-CoV-2, the etiological agent of COVID-19, appears to remain viable for hours to days on surfaces, with duration persistence varying by surface material type.⁴

Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2.

Additional and more detailed information about recommended cleaning protocols, including recommended cleaning procedures following an autopsy of a decedent with confirmed or suspected COVID-19, is provided in the source material.¹

Follow standard procedures when transporting a decedent’s body after specimens have been collected and the body has been bagged. Disinfect the outside of the bag by applying EPA-registered, hospital-grade disinfectant for appropriate contact times as indicated on the product’s label. Wear disposable nitrile gloves when handling the body bag.

How to submit specimens to SCDHEC for COVID-19 testing

Prior to submitting specimens for testing at the DHEC Public Health Laboratory (PHL), you must be enrolled in OpenELIS. If your facility is not enrolled in OpenELIS, please fill out authorized user and confidentiality agreement and send via email to admin@dhec.sc.gov to get a customer ID and access to OpenELIS. Reports are available within 24-48 hours after the sample is received by the PHL.

Samples may be submitted to DHEC without prior approval. A lab requisition form will need to be completed. Please ensure the following mandatory fields are completed for the decedent:

• Name
• ID number
• Date of birth
• Sex
• Sender address (if new sender, please provide phone and fax number)
• Date and time of specimen collection
• Specimen type/source (e.g., 52 nasopharyngeal swabs)
• For TEST REQUESTED, MOLECULAR SECTION check “Other” and write “COVID-19” 

Specimen shipping/transport instructions are included in points #6 and #7 in the DHEC Health Alert Network (HAN) update distributed on March 13, 2020.⁵

At this time, SCDHEC is requesting that all postmortem specimens be sent to the SCDHEC Public Health Laboratory (PHL) for testing. If testing cannot be performed by the PHL, or if test results are inconclusive or otherwise unusual, specimens may be sent to CDC for testing. Additional details about CDC testing of postmortem specimens can be found here.¹

How to obtain COVID-19 test kits

A limited supply of COVID-19 test kits are available from the PHL; send requests via email to PHL-Supply@dhec.sc.gov.

How to report COVID-19 test results

Reporting of Positive Results from Commercial Labs COVID-19 is now considered Immediately Reportable in South Carolina, under the “Novel Infectious Agent” condition in the 2020 South Carolina List of Reportable Conditions. When you receive a positive test from a commercial reference lab, please call the regional epidemiology office of the county where the patient resides to report (contact information can be found at the end of the 2020 list). Epidemiology staff will assist with next steps for case and contact investigation activities.

DHEC contact information for reportable diseases and reporting requirements

“Reporting of Coronavirus Disease 2019 (COVID-19) as a Novel Infectious Agent” is consistent with South Carolina Law requiring the reporting of diseases and conditions to your state or local public health department. (State Law # 44-29-10 and Regulation # 61-20) as per the DHEC 2020 List of Reportable Conditions) 

How to report COVID-19 as a cause of death on a death certificate^6,7

If COVID-19 is known or suspected to have played a role in the death, this condition should be specified on the death certificate. In many cases, it is likely that it will be the underlying cause of death, as it can lead to various life-threatening conditions (e.g., pneumonia, acute respiratory distress syndrome). In these cases, COVID-19 should be reported on the lowest line used in Part I of the death certificate with the other conditions to which it gave rise listed on the lines above it. Generally, it is best to avoid abbreviations and acronyms, but COVID-19 is unambiguous, so it is acceptable to report on the death certificate.

In some cases, survival from COVID-19 can be complicated by pre-existing chronic conditions, especially those that result in diminished lung capacity (e.g., chronic obstructive pulmonary disease, asthma). These medical conditions do not cause COVID-19, but can increase the risk of contracting a respiratory infection and death, so these conditions should be reported in Part II of the death certificate and not in Part I.

When determining whether COVID-19 played a role in the cause of death, follow the CDC clinical criteria for evaluating a person under investigation for COVID-19 and, where possible, conduct appropriate testing. If COVID-19 cannot be formal diagnosis but it is suspected or likely based on clinical judgement, it is acceptable to report COVID-19 on a death certificate as “probable” or “presumed.” Testing for COVID-19 should be conducted whenever possible.

A Clinician Outreach and Communication Activity (COCA) webinar (April 16, 2020) discussing this topic is available online.⁷

Common confusions/problems and examples

• Intermediate causes: these are conditions that typically have multiple possible underlying etiologies and thus, an underlying cause of death must be specified on a line below in Part I of the death certificate. For example, pneumonia is an intermediate cause of death since it can be caused by a variety of infectious agents or by inhaling a liquid or chemical. Pneumonia is important to report in a cause-of-death statement but, generally, it is not the underlying cause of death. The cause of pneumonia, such as COVID-19, needs to be stated on the lowest line used in Part I.
• Specificity: the reported underlying cause of death should be specific enough to be useful for public health and research purposes. For example, a “viral infection” can be an underlying cause of death, but it is not specific. A more specific underlying cause of death in this instance could be “COVID-19.”
• Additional information including more detailed examples are provided in the source material.^6,7

How to specify COVID-19 using ICD-10-CM codes8,9

Effective April 1, 2020, the new ICD-10-CM code U07.1, COVID-19 has been implemented by the National Center for Health Statistics to accurately capture data on mortality attributed to COVID-19.

When COVID-19 meets the definition of principal or first-listed diagnosis, code U07.1, COVID-19 should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients. However, if COVID-19 does not meet the definition of principal or first-listed diagnosis (e.g. when it develops after admission), then code U07.1 should be used as a secondary diagnosis. 

Please see the source material for additional and more detailed information and guidelines about appropriate use of this code.^8,9

How to contact SCDHEC with questions, concerns, or feedback

Send communications via email to esf8@emd.sc.gov.

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The above is a summary of guidance and information from the following sources:

¹ https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-specimens.html

² https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html 

³ https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html

⁴ van Doremalen, N., Bushmaker, T., Morris, D. H., Holbrook, M. G., Gamble, A., Williamson, B. N., ... & Lloyd-Smith, J. O. (2020). Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. New England Journal of Medicine. DOI: 10.1056/NEJMc2004973 https://www.nejm.org/doi/full/10.1056/NEJMc2004973 

⁵ https://www.scdhec.gov/sites/default/files/media/document/10451-DHU-03-13-2020-COVID-19.pdf 

⁶ https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf

⁷ https://emergency.cdc.gov/coca/calls/2020/callinfo_041620.asp

⁸ https://www.cdc.gov/nchs/icd/icd10cm.htm

⁹ https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

https://www.cdc.gov/coronavirus/2019-ncov/faq.html

https://www.nfda.org/covid-19

https://www.nfda.org/news/in-the-news/nfda-news/id/4979