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

Autopsies play a critical role in elucidating the pathogenesis of emerging infectious diseases, particularly in cases involving high-consequence pathogens such as viral haemorrhagic fevers (VHFs). While biosafety concerns have restricted post-mortem examinations in such contexts, the COVID-19 pandemic has renewed interest in autopsy-based research and highlighted both the potential and the gaps in current biosafety protocols. This narrative review outlines autopsy practices in the context of high-consequence infectious diseases (HCIDs) with a focus on VHFs, summarizes reported autopsy cases, explores alternative post-mortem methods, and examines the evolution of legal and institutional frameworks in response to the pandemic. A comparison of official international guidelines shows that while detailed autopsy protocols have been published for pathogens requiring BSL-3 containment - particularly in the United States (US) and United Kingdom (UK) - no official procedural guidance seems to be available for performing autopsies under BSL-4 conditions. Instead, current recommendations at this level are limited to post-mortem handling and disposal of the deceased. This regulatory and procedural gap underscores the urgent need for harmonized, high-containment autopsy protocols that balance biosafety with scientific value. Developing such frameworks will be essential to improve outbreak preparedness and enable evidence-based responses to future pandemics globally. Accordingly, we propose a structured, system-based approach to BSL-4 autopsy practice as a foundation for discussion and future guideline development.