Autopsy practices for high-consequence infectious diseases: global guidelines, alternatives, and the BSL-4 gap

Area of Science:

• Pathology
• Infectious Diseases
• Public Health

Background:

• Autopsies are crucial for understanding disease pathogenesis, especially for high-consequence infectious diseases (HCIDs).
• Biosafety concerns have historically limited postmortem examinations for dangerous pathogens.
• The COVID-19 pandemic highlighted the need for updated autopsy biosafety protocols.

Purpose of the Study:

• To review autopsy practices for HCIDs, focusing on viral hemorrhagic fevers (VHFs).
• To examine existing guidelines and identify gaps in high-containment autopsy procedures (BSL-4).
• To propose a framework for structured BSL-4 autopsy practices.

Main Methods:

• Narrative review of autopsy practices in HCIDs, with emphasis on VHFs.
• Summary of reported autopsy cases in the context of HCIDs.
• Analysis of international guidelines and legal/institutional frameworks.
• Comparison of protocols for BSL-3 versus BSL-4 containment.

Main Results:

• Detailed autopsy protocols exist for BSL-3 pathogens in countries like the US and UK.
• No official procedural guidance is available for performing autopsies under BSL-4 conditions.
• Current BSL-4 recommendations focus primarily on postmortem handling and disposal, not examination.

Conclusions:

• A significant gap exists in harmonized, high-containment autopsy protocols for BSL-4 pathogens.
• There is an urgent need for protocols balancing biosafety with scientific value.
• Developing structured BSL-4 autopsy frameworks is essential for pandemic preparedness and response.