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Biosafety Level of Autopsy Facility

 

Biosafety Level (BSL) Autopsy Facility In Ministry Of Health Hospitals

Department of Forensic Medicine functions and provides mortuary and pathology services under Ministry of Health (MOH) hospitals in Malaysia. The department is equipped with a morgue facility and autopsy room. Autopsy room in most MOH hospitals is a common autopsy room type that can accommodate one to three autopsy tables. Autopsy room is a room or space used for conducting examination on dead body if there is a need to assist police investigation under the instruction of Police 61 issuance. Under the provision of Law in Malaysia, it is stated clearly in Criminal Procedure Code Act 593, Section 329 – 331, police as an investigation officer has the authority to request the nearest government Medical Officer for a postmortem examination. This is called the Medicolegal Postmortem. However, in cases without the Police 61 order, an autopsy can still be performed with the permission of the heirs for the diagnostic purposes. This is called the Clinical Postmortem. Autopsy is performed to determine the cause of death as well as manner of death, such as natural death, accidents, suicide or homicide.

Autopsy room is usually equipped with scales and autopsy table and other autopsy equipment such as blade, autopsy saw and others. Appropriate ventilation systems should be available to avoid unpleasant odors during autopsy. In Malaysia, most hospitals have a mortuary facility with autopsy suite. However, the facilities available in each department of Forensic Medicine may differ accordingly to hospital design and built. All state hospitals under Ministry of Health Hospitals in Malaysia are equipped with proper mortuary facilities. In peninsular Malaysia, Hospital Kuala Lumpur is built-in with Biosafety level 2 plus facility and Hospital Sultanah Bahiyah Alor Setar, Kedah is equipped with Biosafety Level 3 autopsy facility.

For cases of normal deaths, usually not high risk, autopsy will be conducted in the normal autopsy suite. However, if the case involves the death of the suspected high-risk cases such as H1N1, Ebola and other deadly diseases that can cause harm to the public or the mortuary personnel, autopsy will be conducted in the autopsy room BSL-2 and above. Autopsy room labeled BSL-2 and above is safe to carry out a high risk autopsy examination as the room is well-equipped with good ventilation and protection to the mortuary personnel. In this type of autopsy room, there is ventilation with gas-tight interlocking doors, negative pressure crossing different zones and a high rate of air-exchange. This means that the air comes in from one direction and goes out in the other direction. Figure 1 shows an example of a BSL-3 autopsy suite.


Figure 1 : Biosafety Level 3 autopsy suite
(Source : New Maryland Medical Examiner’s Facility)

Autopsy-transmitted infections may occur after direct cutaneous (percutaneous) injury, contact with droplets, or after aerosol exposure. Autopsy personnel are particularly at risk due to the nature of work performed on infected bodies, and the high frequency of percutaneous injury through the use of autopsy machinery and utensils. In the past, autopsy personnel have died from autopsy-transmitted Marburg, Ebola, Lassa Hemorrhagic Fever Viruses (Nolte et al, 2001) Hence, in BSL-2 and above, there is pass-through decontamination chamber to send or retrieve items from within the autopsy room and from outside (Refer Figure 3). The use of this pass through chamber is to prevent any infection to the personnel outside the room.


Figure 2 : Facility in a BSL-3 Autopsy room
(Source : LEED Gold BSL-3 Forensic Pathology Autopsy Lab)

Similarly, for the storage of the highly infectious bodies, there are special allocated body freezer. There are two doors to be opened from the inside of the BSL autopsy room and from the outside of the room. This is to facilitate the transfer of the bodies from the freezer to the autopsy room without the need of passing through the common space used by other personnel in the mortuary.


Figure 3 : ‘3D’ Rendering of the Autopsy Suite and the Pass through Decontamination Chamber (Paul Chui et al., 2007)

Comprehensive decontamination system in BSL rooms which includes Air-HEPA double filtration and UV cleaning of exhaust air before leaving the room and subsequent discharge into the environment. HEPA filtered air supply into the autopsy room with carbon filters in the exhaust room. All equipment and tools used will be decontaminated after the procedure. Liquid waste and solid waste will be decontaminated and treated chemically prior to further processing. Bodies are washed and decontaminated before enclosed in a sealed (first) body bag. This body bag will then be decontaminated on the outside and enclosed in another (second) body bag. All infectious materials such as samples will be placed in a sealed containers and decontaminated before pass through the chamber to be sent to laboratories.

Equipment in the BSL autopsy room should not be shared with other equipment used in the course of normal autopsy. This is to avoid cross-contamination of equipment. However, each time completing the autopsy, all equipment will be washed with particular detergent to kill germs and bacteria.

Biological safety levels have been clearly established for biomedical and microbiological laboratories (U.S. Department of Health and Human Services, 1999). The same levels and principles be introduced to autopsy facilities now. Safety guidelines for autopsy personnel indicate that any autopsy can potentially result in exposure to a biological hazard classified as RG 2, 3, or 4. Nolte et al. (2001) concluded that the biosafety principles that have been developed for clinical laboratories, biomedical research laboratories and animal facilities could be broadly applied to autopsy facilities. The Biosafety levels are as follow (Paul Chui et al., 2007).

  • BSL-2 provides personal protection against the majority of bloodborne pathogens. BSL-2 associated practices form part of the standard hygienic procedures and precautions applied to normal medical operations within healthcare facilities.
  • BSL-3 procedures provide protection to healthcare participants in an environment of risk to harmful agents spread by aerosols such as Mycobacterium tuberculosis, rabies and Yersinia pestis. BSL-3 principles are suitable for work with indigenous or exotic agents that can cause serious or potentially lethal disease as a result of exposure by the inhalation route.
  • BSL-4 containment conditions are required when operators may be exposed to dangerous and exotic agents, which pose a high risk of aerosol-transmitted exposures to agents causing life-threatening diseases for which there are no prophylactic or post-exposure treatments.

To emphasize the safety of personnel involved, the door to enter the autopsy room is different to the exit so that no contamination will occur before and after the autopsy is conducted. Upon entering the room for autopsy procedure, the staff involved should wear sufficient safety protection equipment. Only staff with clean clothes are allowed to exit to the clean area while dirty clothes will be left in the autopsy room for cleaning purposes.

Recent threats of bioterrorism, outbreaks of previously unknown infectious diseases such as Severe Acute Respiratory Syndrome (SARS) and the re-emergence of diseases like the Avian Influenza are very real and have caused serious concerns not only for the world-at-large, but also for many authorities. This is an even greater concern for the forensic community as they are generally ill-equipped to deal with highly infectious pathogens due to chronic under funding and administrative constraints. The cost for building a Biosafety Level facility is exorbitant; such a facility is also very expensive to operate and maintain. This is the current challenge faced by Ministry of Health in Malaysia. Other alternatives like suggested by Paul Chui et al. (2007) can be put under future planning consideration, where an innovative mobile BSL-3 or -4 autopsy suite container can be constructed and deployed to distant locations for the conduct of highly infectious cases.

References

  1. Nolte K. B. The Potential Role of Medical Examiners and Coroners in Responding to and Planning for Bioterrorism and Emerging Infectious Diseases. Homeland Security and Emergency Preparedness. Medicolegal death Investigation Systems : Workshop summary. Pg 52. 2003.
  2. Nolte K. B., Taylor D. G. and Richmond J. Y. Autopsy Biosafety IV : Issues in Public Health. American Biological safety Association. Pg. 1. 2001.
  3. Paul Chui, Peter Chong, Bobby Chong and Stefan Wagener. Mobile Biosafety Level-4 Autopsy Facility – An Innovative Solution. Applied Biosafety. Vol. 12. Pg. 238 – 244. 2007.
  4. U. S Department of Health and Human Services, Centers for Disease Control and Prevention & National Institutes of Health. Biosafety in Microbiological and Biomedical Laboratories. 4th Edition. Pg. 47 – 53. Washington DC, US Government Printing Office.
Last Reviewed : 19 May 2015
Writer : Mohd Hilmi bin Saidin
Accreditor : Khoo Lay See