Autopsy and Handling of Human Remains

All post-mortem procedures require adherence to standard precautions with the use of appropriate personal protective equipment (PPE) and facilities with appropriate safety features.

When possible, personnel with an up-to-date smallpox vaccination (within 3 years) should participate in autopsy or mortuary care for patients with confirmed or suspected monkeypox. If unvaccinated personnel must be utilized, persons without contraindications to vaccination are preferred.

Transfer of Human Remains

Personnel who perform post-mortem care of remains should wear PPE as recommended for Standard, Contact and Airborne Precautions [PDF – 226 pages]. The body should be prepared following routine healthcare facility procedures for cleaning and containing body fluids and then wrapped in a plastic shroud. Wrapping should be done in a manner that prevents contamination of the outside of the shroud; a change of gown and gloves may be necessary.

If an autopsy will be performed, the shrouded body should be placed on a mortuary stretcher and covered with a clean linen sheet for transportation to the morgue. If the remains will go directly to a mortuary, they should be placed in a body bag prior to removal. Persons transporting prepared and covered human remains should wear gloves but other PPE is not required.

Personal Protective Equipment and Facility Design for Autopsy

Persons who transfer remains from a mortuary stretcher onto the autopsy table should wear a gown and gloves. Personnel who perform or assist with the autopsy should wear the following PPE as required for Standard, Contact and Airborne Precautions [PDF – 226 pages] in the autopsy setting.

• Protective garments: surgical scrub suit, surgical cap, impervious gown with full sleeve coverage, eye and face protection (e.g., face shield), shoe covers and double surgical gloves with an interposed layer of cut-proof synthetic mesh gloves.
• Respiratory protection: N95 or N100 respirators; or powered air-purifying respirators (PAPR) equipped with a high efficiency particulate air (HEPA) filter. A PAPR is recommended for any procedures that may result in mechanical generation of aerosols (e.g., use of oscillating saws). Autopsy personnel who cannot wear N95 respirators because of facial hair or other fit-limitations should wear PAPRs.
• Handling of protective equipment: protective outer garments must be removed when leaving the immediate autopsy area and discarded in appropriate laundry or waste receptacles, either in an antechamber to the autopsy suite or immediately inside the entrance if an antechamber is not available. Hands should be washed upon glove removal.

Before an autopsy begins the following engineering strategies and facility designs should be considered:

• Air handling systems: autopsy suites must have adequate air-exchanges per hour, and correct directionality and exhaust of airflow. Autopsy suites should have a minimum of 12 air-exchanges per hour and should be at a negative pressure relative to adjacent passageways and office spaces. Air should not be returned to the building interior, but should be exhausted outdoors, away from areas of human traffic or gathering spaces (e.g., off the roof) and away from other air intake systems. For autopsies, local airflow control (i.e., laminar flow systems), can be used to direct aerosols away from personnel; however, this safety feature does not remove the need for appropriate personal protective equipment.
• Doors and windows: during autopsy, keep doors and windows to autopsy suite closed.
• Containment devices: biosafety cabinets should be available for handling and examination of smaller specimens. Oscillating saws are available with vacuum shrouds to reduce the amount of particulate and droplet aerosols generated. These devices should be used whenever possible to decrease the risk of occupational exposure.

Autopsy Procedures and Specimen Collection

The following safety procedures should be used for autopsies and post-mortem assessment of monkeypox cases:

• Prevention of percutaneous injury: all sharps should be carefully handled, never recap, bend or cut needles, and ensure that appropriate sharps containers are available.
• Procedures: The number and extent of procedures should be minimized, both to decrease opportunities for worker risk and the potential for environmental contamination. Perform autopsies only to the extent required to obtain needed information. Omit examinations that generate aerosols and increase the risk of environmental contamination (e.g., the use of oscillating saws to open the skull).

All major organs should be sampled. Particular attention and extensive sampling should include tissues demonstrating gross pathology or involvement as suggested by clinical presentation. Autopsy specimens should include:

• Skin
• Spleen
• Lymph nodes and tonsils
• Liver
• Lung
• Kidney
• Heart

Place representative tissues in 10% buffered formalin for immunohistochemical or histopathologic evaluation and store at room temperature.

Representative fragments of tissues listed above should be collected using sterile techniques and placed in sterile 1.5-2 mL screw-capped plastic vials with O-ring. DO NOT ADD ANY VIRAL TRANSPORT MEDIA. Specimens should be refrigerated at 4⁰C if shipment will occur within 24 hours, otherwise specimens may be frozen. For more information on labeling and packaging specimens for transport read Submitting Specimens to CDC Shipping and Packing.

After specimen collection:

• All non-reusable specimen collection and barrier protection materials should be placed in biohazard bags for handling as medical waste.
• All reusable equipment should be cleaned and disinfected according to standard laboratory procedures.
• All surfaces should be thoroughly cleaned and with 0.5% sodium hypochlorite or other EPA approved high level disinfectant.