Autopsies are an essential tool for understanding new diseases. When it comes to emerging infectious diseases such as COVID-19, autopsies help to shape our understanding of what a virus can do to the body and how we might combat it. Dr Linda Iles is Head of Forensic Pathology Services at the Victorian Institute of Forensic Medicine. She explains that although few COVID-19 autopsies are being performed in Australia and New Zealand, there has been worldwide recognition for their role in increasing the understanding of the multisystem effects of the SARS-CoV-2 virus.

“Tissue obtained at autopsy (in appropriately consented studies) can provide information regarding the pathological basis of COVID-19. By looking at changes in tissue under the microscope, and in some cases carrying out genetic tests, pathologists are able to detail the damage the virus is causing. This damage is ultimately what causes the serious signs and symptoms of COVID-19. The need for this information is important to improve patient management of mild and severe illness, and also to guide treatment strategies. Whilst the Royal College of Pathologists of Australasia has a policy of actively encouraging safe autopsy practice to increase understanding of COVID-19, few hospital autopsies have been performed in Australia and New Zealand.

“It is unclear why this is the case given that appropriately equipped hospital mortuaries are already able to safely perform autopsies for other HG3 (hazard grade 3) pathogens. Local and international experience has also demonstrated that COVID-19 autopsies can be performed safely when appropriate PPE is available and precautions are taken, without compromising the health and safety of pathologists and mortuary staff. Unfortunately, this is reflective of an ongoing trend away from consented hospital autopsies and highlights the loss of valuable opportunities to contribute to the deeper clinical understanding of this novel pathogen and its potential treatments,” said Dr Iles.

In other parts of the world, autopsies have been performed to varying degrees. For example, in Hamburg, the importance of autopsy in understanding COVID-19 was recognised by public health authorities early in 2020. Autopsies were therefore strongly encouraged (and funded) in those suspected to have died from COVID-19. In the USA, although hospital systems were too overwhelmed to manage autopsies at the start of the pandemic to, the first post-mortem reports began to emerge by late May and June 2020.

“Advances in medical imaging have reduced the need for autopsies but in the case of COVID-19, autopsies have led to discoveries which have helped us to understand the disease. Early in the pandemic, autopsy findings confirmed clinical impressions of venous thromboembolism (blood clots in the veins), contributing to morbidity and mortality in those with COVID-19. Subsequently, post-mortem studies have contributed to the understanding of the role of microvascular injury (damage to small blood vessels) in the multisystem pathology of COVID-19.

“What’s more, it is extremely difficult to determine the cause of death unless an autopsy is performed. Autopsies have therefore played a fundamental role in differentiating those dying from COVID-19 from those dying with co-incidental SARS-CoV-2 infection, and those dying from a combination of pre-existing disease with a variable contribution from COVID-19. There is also a very significant role for autopsy in deaths following immunisation. It is important that we are able to distinguish between deaths that occur as a consequence, either directly or indirectly, of immunisation, as opposed to deaths which happen co-incidental to vaccination, which is a much more common scenario,” said Dr Iles.

Finally, information taken from autopsies can assist in developing new treatments, both via providing pathological data to treating clinicians, and tissue for consented research projects. This may be as simple providing data around rates of venous thrombosis (colloquially known as blood clots) in COVID-19 patients, informing the use of anti-coagulant therapies, through to providing tissue for research projects.