CORD-19_Custom_license_subset  

CORD-19:112d99dcf6554496b5dd4ce4696ff2850647388a JSONTXT 8 Projects

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Id Subject Object Predicate Lexical cue
T1 0-8 Sentence denotes Abstract
T2 9-125 Sentence denotes In the United States of America, Medical Examiners and Coroners (ME/Cs) investigate approximately 20% of all deaths.
T3 126-413 Sentence denotes Unexpected deaths, such as those occurring due to a deceased person under investigation for a highly infectious disease, are likely to fall under ME/C jurisdiction, thereby placing the ME/C and other morgue personnel at increased risk of contracting an occupationally acquired infection.
T4 414-433 Sentence denotes This survey of U.S.
T5 434-598 Sentence denotes ME/Cs′ capabilities to address highly infectious decedents aimed to determine opportunities for improvement at ME/C facilities serving a state or metropolitan area.
T6 599-657 Sentence denotes Data for this study was gathered via an electronic survey.
T7 658-836 Sentence denotes Of the 177 electronic surveys that were distributed, the overall response rate was N = 108 (61%), with 99 of those 108 respondents completing all the questions within the survey.
T8 837-916 Sentence denotes At least one ME/C responded from 47 of 50 states, and the District of Columbia.
T9 917-1127 Sentence denotes Select results were: less than half of respondents (44%) stated that their office had been involved in handling a suspected or confirmed highly infectious remains case and responses indicated medical examiners.
T10 1128-1297 Sentence denotes Additionally, ME/ C altered their personal protective equipment based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach.
T11 1298-1765 Sentence denotes Standard operating procedures or guidelines should be updated to take an all-hazards approach, bestpractices on handling highly infectious remains could be integrated into a standardized education, and evidence-based information on appropriate personal protective equipment selection could be incorporated into a widely disseminated learning module for addressing suspected or confirmed highly infectious remains, as those areas were revealed to be currently lacking.
T12 1767-1955 Sentence denotes Increased international travel and exchange are factors that escalate the risk for rapid transmission of emerging and reemerging infectious diseases, and highly infectious diseases (HIDs).
T13 1956-2422 Sentence denotes While neither the Centers for Disease Control and Prevention (CDC) nor the World Health Organization (WHO) has formally published a current standard list of pathogens deemed to be highly infectious, multiple 'priority' pathogens (e.g. coronaviruses, viral hemorrhagic fever viruses, Bacillus anthracis, Yersinia pestis) are frequently cited as requiring advanced resources, protocols, and training to minimize risk of disease transmission and mortality [1] [2] [3] .
T14 2423-2711 Sentence denotes The 2014-2016 West Africa Ebola virus disease (EVD) outbreak, for example, challenged the capabilities, capacities, and efficacy of healthcare facilities in caring for patients with a highly infectious pathogen both abroad and in the United States [4] [5] [6] [7] [8] [9] [10] [11] [12] .
T15 2712-3137 Sentence denotes In addition to the direct clinical care provided to patients with confirmed and suspected EVD, public health departments and other affiliated sectors including emergency management, clinical and research laboratories, medical waste management, and mortuary services collaborated with medical providers to optimize and support patient care while reducing the risks to environmental and public safety [13] [14] [15] [16] [17] .
T16 3138-3357 Sentence denotes Due to the highly infectious nature of EVD, comprehensive aspects of infection prevention-including appropriate handling of highly infectious remains-had to be carefully considered and planned to contain disease spread.
T17 3358-3603 Sentence denotes Careful handling of highly infectious remains was particularly imperative given that viral loads were found to be high immediately after an EVD-infected individual died, thereby posing hazardous to pathology and mortuary personnel [16, 18, 19] .
T18 3604-3846 Sentence denotes The risk of infection for death care sector workers posed by HIDs was exemplified by the 2016 infection of a German mortuary worker with Lassa fever following the processing of remains previously unknown to be infected with Lassa virus [20] .
T19 3847-4222 Sentence denotes At the height of the 2014-2016 outbreak, the CDC published guidelines for handling EVD-infected human remains informed by evidence-based best practices to address the transmission risk posed to workers [18] ; however, a recent gap analysis survey of the U.S. death care sector-specifically of funeral homes and crematories-revealed that most were unaware of these guidelines.
T20 4223-4411 Sentence denotes Overall, the study found a lack of up-to-date education, training and resources provided to this industry to safely manage potential or confirmed highly infectious remains scenarios [21] .
T21 4412-4607 Sentence denotes As EVD is now re-emerging in other regions of Africa [22] and incidence and mortality of other infectious diseases is globally on the rise, the concerns raised in this study remain ever relevant.
T22 4608-4812 Sentence denotes Thus, it is imperative for those working with potentially infected human remains to receive the requisite training and resources to enable effective disease containment and prevent secondary transmission.
T23 4813-4936 Sentence denotes In the United States of America (U.S.), Medical Examiners and Coroners (ME/Cs) investigate approximately 20% of all deaths.
T24 4937-5064 Sentence denotes Typically, MEs are physicians, usually pathologists specializing in forensic pathology, who are appointed government officials.
T25 5065-5226 Sentence denotes They are charged with investigating unexpected, suspicious, and unnatural deaths in order to determine cause and manner of death and perform autopsies as needed.
T26 5227-5411 Sentence denotes Coroners, conversely, could be non-physicians or nonpathologist physicians who are elected or appointed at the county level; they look into deaths similar to those investigated by MEs.
T27 5412-5477 Sentence denotes Coroners largely rely upon pathologists to perform the autopsies.
T28 5478-5759 Sentence denotes Unexpected deaths, such as those occurring due to a deceased person under investigation (PUI) for a HID, are likely to fall under ME/C jurisdiction, thereby placing the ME/C and other morgue personnel at increased risk of contracting an occupationally acquired infection [23, 24] .
T29 5760-5854 Sentence denotes Historically, ME/Cs have often been among the first to encounter infectious disease outbreaks.
T30 5855-6083 Sentence denotes For instance, ME/C offices were instrumental in recognizing outbreaks of diseases such as Hantavirus pulmonary syndrome, West Nile encephalitis, and novel severe acute respiratory syndrome coronavirus (SARS-CoV) [25] [26] [27] .
T31 6084-6297 Sentence denotes While the CDC recommends that no autopsy be performed for a confirmed patient with Ebola virus disease, it is likely that if a patient were to die from an unidentified HID that an autopsy would be conducted [18] .
T32 6298-6482 Sentence denotes Additionally, ME/C offices play a critical role in discovering the pathogenesis of infectious diseases as well as providing a means of disease surveillance on a global level [28, 29] .
T33 6483-6644 Sentence denotes In Puerto Rico, ME/C autopsy samples have been used to track Dengue virus fatalities, while in South Asia they have diagnosed deaths due to emergent Nipah virus.
T34 6645-6800 Sentence denotes ME/C offices have also helped demonstrate the lethality of pediatric influenza and confirmed deaths due to Creutzfeldt-Jakob disease (CJD) [30] [31] [32] .
T35 6801-7197 Sentence denotes Despite the essential role ME/C offices play in public health, there have been multiple published reports of considerable obstacles to effective infectious disease and mortality surveillance including the following: inadequate morgue biosafety infrastructure, lack of appropriate staff training/ educational updates, and critical shortages in the numbers of forensic pathologists [31] [32] [33] .
T36 7198-7367 Sentence denotes Uncertainties persist on the capabilities of ME/C offices to address increasing baseline case volumes, of which the majority are lower risk infectious disease scenarios.
T37 7368-7555 Sentence denotes Disease containment, in this setting, including prevention of secondary transmission, is critical for the benefit of public health, emergency management, medicine, and the general public.
T38 7556-7918 Sentence denotes Given the critical role ME/Cs play in this endeavor, and the apparent lack of resources dedicated to this sector of the workforce to protect themselves from potential occupational exposures, this study was conducted to evaluate what protocols are in place for suspected or confirmed highly infectious remains, as well as determining levels of training among U.S.
T39 7919-7961 Sentence denotes ME/Cs to handle highly infectious remains.
T40 7962-8110 Sentence denotes Total population purposive sampling was utilized for this nonexperimental design, as each state has its own unique death investigation system [34] .
T41 8111-8325 Sentence denotes A contact list of ME/C offices serving populations of 300,000 or greater was compiled for each state by the National Association of Medical Examiners (NAME) Ad Hoc Committee for Bioterrorism and Infectious Disease.
T42 8326-8507 Sentence denotes This minimum population limit was selected in an effort to avoid duplication of survey results, as geographic areas with smaller populations often outsource to larger ME/ C offices.
T43 8508-8755 Sentence denotes An electronic survey with questions created by the authors was distributed via Qualtrics© (Software Version 2016.17, Provo, UT) through a link in an email solicitation (Indiana University Institutional Review Board exemption protocol #1711094822).
T44 8756-9103 Sentence denotes Survey questions included: demographic information (e.g. title, population served, state), personal protective equipment (PPE) worn in different infectious scenarios, procedures performed in different infectious scenarios, duration of training received, biosafety level (BSL) capabilities, and jurisdictional handling of highly infectious remains.
T45 9104-9327 Sentence denotes The NAME Ad Hoc Committee for Bioterrorism and Infectious Disease sent email solicitations from December 5, 2017 to February 6, 2018 to encourage responses from ME/C offices nationwide, ensuring a comprehensive view of U.S.
T46 9328-9343 Sentence denotes ME/C practices.
T47 9344-9380 Sentence denotes The survey was closed after 9 weeks.
T48 9381-9525 Sentence denotes Data from Qualtrics© was exported and data was analyzed utilizing SAS Version 9.4 (Copyright (c) 2002-2012 by SAS Institute Inc., Cary, NC, US).
T49 9526-9798 Sentence denotes Frequencies and percentages were used to summarize question responses and chi-square tests were performed to investigate associations between variables; only significant findings were reported and individual states were not named to protect the identity of the State ME/C.
T50 9799-9884 Sentence denotes All responses to questions were voluntary so response rates between questions varied.
T51 9885-10051 Sentence denotes Of the 177 electronic surveys that were distributed, the overall response rate was N = 108 (61%), with 99 of those 108 completing all the questions within the survey.
T52 10052-10247 Sentence denotes At least one ME/C responded from 47 of 50 states, and the District of Columbia; three states were excluded because their largest ME/C office did not serve a population size of 300,000 or greater.
T53 10248-10426 Sentence denotes Medical examiners represented the majority of respondents (68%), followed by Coroners (18%) and 'Other' titles (14%) (e.g. Forensic Pathologist, Deputy Coroner, Sheriff-Coroner).
T54 10427-10568 Sentence denotes There appeared to be a difference in distribution of professions across the region, with MEs being more evenly distributed than other titles.
T55 10569-10766 Sentence denotes Each U.S. region, as delineated by the Department of Health and Human Services, had at least 3 medical examiners, while several regions had zero or one respondent who selected 'Coroner" or 'Other'.
T56 10767-10926 Sentence denotes For coroners, 35% were from the Midwest (IL, IN, MI, MN, OH, and WI) and 40% of those who selected 'Other' were from the west coast (AZ, CA, HI, and NV) [35] .
T57 10927-11198 Sentence denotes Twenty-five percent of respondents worked in an office that served a population size between 300,000-500,000; 16% served 500,001-750,000; 15% served 750,001 up to 1 million and 44% of respondents came from an office that served a population greater than 1 million people.
T58 11199-11515 Sentence denotes When asked which entity was responsible for their office's oversight, 60% stated a government agency, 16% public safety or law enforcement, 13% 'other' (academic medical center or university, city or county health department, political subdivision, or self), 8% state health department, and 3% a forensic laboratory.
T59 11516-11968 Sentence denotes Respondents were asked to select all PPE worn when performing standard duties, i.e. when no known infectious disease outbreak was occurring locally or regionally or was reported to the ME/C (Table 1) . 'Other' optional items of PPE listed were: a plastic apron over the surgical gown (n = 6), waterproof sleeve covers (n = 5), hair nets/bonnets (n = 2), dedicated autopsy socks (n = 1), and one respondent noted use of a Tyvek suit for standard duties.
T60 11969-12450 Sentence denotes For comparison, respondents were asked to select what PPE they would wear when performing duties on suspected or confirmed highly infectious remains (Table 1) . 'Other' optional items of PPE listed were: disposable apron (n = 7), waterproof sleeves (n = 5), hair net/bonnet (n = 2), self-contained breathing apparatus (SCBA) (n = 1), Hazardous Waste and Emergency Response standard (HAZWOPER) gear (n = 1), Tyvek suit (n = 1), and two layers of clothes (cloth and plastic) (n = 1).
T61 12451-12530 Sentence denotes Four respondents stated their office would not perform autopsies on such cases.
T62 12531-12907 Sentence denotes Slightly more than half of respondents (56%; 61/108) stated their office staff had received training on donning and doffing PPE in suspected or confirmed cases of highly infectious remains; nearly one-third (32%) (18/56) reported the amount of cumulative training in hours per person, on average per year, was 1 h or less while 29% (16/56) spent between 1 and 2 h of training.
T63 12908-12982 Sentence denotes The entity that provided the PPE training varied widely among respondents.
T64 12983-13437 Sentence denotes Common responses included: in-house staff (n = 16), state or local health department (n = 7), an affiliated university (n = 6), occupational health or a safety and compliance coordinator external to the ME/C office (n = 6), online-based training (n = 3), risk or emergency management (n = 3), an infectious disease or infection control specialist (n = 3), or individuals highly trained in hazardous materials (HAZMAT) external to the ME/C office (n = 2).
T65 13438-13593 Sentence denotes In the event of suspected highly infectious remains, respondents were asked what procedures would be permissible and performed by their office ( Table 2 ).
T66 13594-13981 Sentence denotes The most frequent responses for 'Other' were: dependent on a case-by-case basis/contingent upon suspected pathogen (n = 16), sending the remains to the appropriate biocontainment facility (n = 3), and one noted a written policy for handling highly infectious remains does not exist and would require discussion with multiple stakeholders, including the safety committee to evaluate risk.
T67 13982-14316 Sentence denotes For comparison, respondents were asked which procedures or tasks would be performed in the event of confirmed highly infectious remains (Table 2) . 'Other' responses echoed those in a suspected case where it was dependent on the circumstances and suspected pathogen, or only as required by the CDC or local health department (n = 16).
T68 14317-14449 Sentence denotes One respondent stated they would decline jurisdiction if no circumstance beyond the confirmed infectious disease made it reportable.
T69 14450-14605 Sentence denotes Less than half of respondents (44%; 44/101) stated that their office had been involved in handling a suspected or confirmed highly infectious remains case.
T70 14606-15257 Sentence denotes The most commonly encountered highly infectious pathogens were: CJD and unclassified prions (n = 21); forms of tuberculosis (including extremely drug-resistant [XDR-TB] and multiple drug resistant [MDR-TB]) (n = 13); forms of meningitis (Streptococcus pneumoniae, meningococcal) (n = 9); anthrax (Bacillus anthracis) (n = 6); suspected cases of Ebola and other hemorrhagic fevers (n = 4); human immunodeficiency virus (HIV) a Percentages add up to more than 100% because this question was multiple-select a Percentages add up to more than 100% because this question was multiple-select (n = 3); H1N1 influenza (swine strain) (n = 3); and SARS (n = 2).
T71 15258-15438 Sentence denotes While just under half of the respondents stated their office had been involved in handling such remains (44%; 44/101), those cases do not appear equally distributed across regions.
T72 15439-15627 Sentence denotes No respondents from upper west coast states (AL, ID, OR, WA) reported office involvement, while all respondents from east coast states (CT, ME, MA, NH, RI, VT) reported office involvement.
T73 15628-15709 Sentence denotes Other regions had between 22% to 60% of respondents reporting office involvement.
T74 15710-15967 Sentence denotes Eighty-one percent (81/100) of respondents did not have a Biosafety Level 3 (BSL-3) facility within their office to conduct examinations in suspected highly infectious cases; some did have BSL-1 capabilities (40%; 31/77) and BSL-2 capabilities (60%; 46/77).
T75 15968-16021 Sentence denotes Table 3 provides definitions of the BSL levels [36] .
T76 16022-16741 Sentence denotes In regard to the location at which autopsies were performed in a suspected highly infectious remains case, 58% (47/81) stated there was a separate autopsy area where no other autopsies were being performed at the same time; 20% (16/81) stated they do not examine suspected highly infectious remains at their facility; and 22% indicated 'other', which include not having a separate room/in the regular autopsy area (n = 4), altering protocol to limit staff and only have that single case autopsied at the time if there was not a separate room available (n = 3), performing autopsy in a negative pressure disaster portable morgue unit (n = 1), and that autopsy was contingent on the case load and space available (n = 1).
T77 16742-16870 Sentence denotes One open-ended comment emphasized that it was case dependent, and that "TB gets autopsied, Ebola straight to the funeral home" .
T78 16871-17183 Sentence denotes This statement raises concern as the study by Le et al. that surveyed the level of education and training received by U.S. funeral home and crematory personnel on highly infectious disease mitigation and management revealed large gaps in knowledge, including incorrectly marking routes of exposure for EVD [21] .
T79 17184-17378 Sentence denotes More than half (62%; 62/100) indicated that their staff was not trained to carry out specialized decontamination procedures following autopsy of suspected or confirmed highly infectious remains.
T80 17379-17599 Sentence denotes Of those who had been trained on decontamination procedures, the most frequent response for the average cumulative length of training in hours per year per person was 1 h or less (20%; 7/35), followed by 2 h (17%; 6/35).
T81 17600-17869 Sentence denotes Additionally, a little over one-third of respondents (34%; 33/ BSL-2 builds upon BSL-1 but includes additional precautions and facility features which are appropriate for work with moderate-risk microorganisms that are associated with human disease of varying severity.
T82 17870-17925 Sentence denotes Laboratory access is restricted when work is conducted.
T83 17926-17990 Sentence denotes Enhanced engineering controls and personal protection is needed.
T84 17991-18078 Sentence denotes PPE typically includes lab coats and gloves; eye protection and face shields as needed.
T85 18079-18160 Sentence denotes In addition to the sink for handwashing, there should also be an eyewash station.
T86 18161-18262 Sentence denotes All aerosol or splash-generating procedures should be performed in a biological safety cabinet (BSC).
T87 18263-18412 Sentence denotes There must be an autoclave or alternate method of decontamination for proper waste disposal, and the facility must have self-closing, lockable doors.
T88 18413-18519 Sentence denotes An example of an organism appropriate for use in a BSL-2 laboratory is human immunodeficiency virus (HIV).
T89 18520-18545 Sentence denotes Biosafety Level-3 (BSL-3)
T90 18546-18781 Sentence denotes BSL-3 builds upon the requirements of BSL-2 but includes additional precautions and facility features which are appropriate for work with microorganisms which cause serious or potentially fatal disease through respiratory transmission.
T91 18782-18847 Sentence denotes Access to the facility is restricted and controlled at all times.
T92 18848-18981 Sentence denotes In addition to all the aforementioned PPE, respirators may be worn and are required when experimentally infected animals are present.
T93 18982-19030 Sentence denotes All microorganisms must be handled within a BSC.
T94 19031-19237 Sentence denotes A hands-free sink and eyewash station must be available near an exit, exhaust air cannot be recirculated and the facility must have sustained directional airflow from clean areas to more contaminated areas.
T95 19238-19324 Sentence denotes Lastly, entrance into the facility is through two sets of self-closing, locking doors.
T96 19325-19690 Sentence denotes An example of an organism appropriate for use in a BSL-3 laboratory is Severe Acute Respiratory Syndrome (SARS) coronavirus. a These definitions are paraphrased from those provided by the Centers for Disease Control and Prevention [36] 97) indicated staff were trained to handle and transport (i.e. package and ship) specimens for suspected highly infectious cases.
T97 19691-20034 Sentence denotes If staff were trained, specimens were sent most frequently to one or two of the following locations: the CDC (n = 14), state reference laboratory (n = 13), the National Prion Disease Pathology Surveillance Center (NPDPSC) at Case Western Reserve University for prion diseases (n = 4), or an academic medical center/hospital laboratory (n = 3).
T98 20035-20273 Sentence denotes Of those that had received training on handling and transporting specimens, the most frequent response for the average cumulative length of training in hours per year per person was 1 h (41%; 11/27), followed by less than 1 h (11%; 3/27).
T99 20274-20522 Sentence denotes There was a statistically significant relationship determined between those answering "No" to their office being involved in handling highly infectious remains and those answering "No" to receiving training to safely handle/transport the specimens.
T100 20523-20753 Sentence denotes For those who answered "No" to involvement, 78% had no training for transporting specimens and 21% did; however, for those who answered "Yes" to office involvement, only 51% had training for transporting specimens and 49% did not.
T101 20754-20970 Sentence denotes When asked what their jurisdiction permitted for highly infectious remains, 13% (16/124) stated embalming was permitted, 15% (18/124) traditional burial practices, 25% (31/124) cremation and 47% (58/124) were unsure.
T102 20971-21093 Sentence denotes 1 Survey respondents also had the opportunity to provide open-ended comments at the end of the survey; 26 respondents did.
T103 21094-21757 Sentence denotes Comments included: a desire for formalized or more frequent training in the area of handling highly infectious remains (n = 7); a need for more resources or a lack of preparedness or appropriate facilities to address highly infectious remains (n = 7); the difficulty of answering questions pertaining to newly emerging and re-remerging highly infectious diseases because policies had not been written or revised (n = 4); a need to formalize and update protocols (n = 3); and a need for better funding to attract more prospective forensic pathologists to practice and to purchase greater stocks of PPE since what was available was expired or on back-order (n = 1).
T104 21758-22061 Sentence denotes Select direct quotations and themes included that the, "national infrastructure for autopsy biosafety is woefully inadequate" and a perception of being overlooked/neglected in infection control training but still an office "they hand bodies off to" without regard for the limited training and resources.
T105 22062-22219 Sentence denotes As sudden unexpected deaths fall under Medical Examiner/ Coroner jurisdiction, they may play a fundamental role in the response to infectious disease deaths.
T106 22220-22519 Sentence denotes If communication between various health sectors is unclear or protocols have not been established by the local health department, there is a risk for occupational exposure for all parties involved, and the potential for a ME/C to be exposed to a highly infectious death that has yet to be confirmed.
T107 22520-22704 Sentence denotes The logistical challenges associated with the response to highly infectious pathogens is demanding for public health sectors focused on the treatment and management of living patients.
T108 22705-22873 Sentence denotes The role of the death care sector in effective disease surveillance and containment of infectious diseases is often overlooked; including the fundamental role of ME/Cs.
T109 22874-22980 Sentence denotes ME/Cs frequently investigate deaths with little clinical information on the circumstances preceding death.
T110 22981-23225 Sentence denotes Hence, it is crucial to for ME/Cs to have robust, up-todate education and training in potential highly infectious remains handling, PPE donning and doffing, and clear protocols used when handling human remains that stress universal precautions.
T111 23226-23393 Sentence denotes To determine what training areas are insufficient or need to be supplemented, this survey evaluated current ME/C office capability to handle highly infectious remains.
T112 23394-23550 Sentence denotes This survey provided a national view of the handling of highly infectious remains by capturing a sample of ME/Cs from nearly every state and Washington D.C.
T113 23551-23680 Sentence denotes Medical examiners comprised the majority of the survey respondents and were more evenly geographically distributed than coroners.
T114 23681-23888 Sentence denotes Nearly half of the respondents served large counties or metropolitan areas with populations of greater than one million people, highlighting the large populations that may be covered by a single ME/C office.
T115 23889-23997 Sentence denotes Additionally, most ME/C offices, including the body storage areas (morgues), are under government oversight.
T116 23998-24232 Sentence denotes In order to gauge circumstance-dependent PPE use among ME/Cs, respondents were asked for standard PPE ensembles worn during routine autopsies and those worn for autopsies on suspected or confirmed highly infectious remains (Table 1) .
T117 24233-24420 Sentence denotes Slightly more than half (52%) reported wearing an N95 respirator during routine autopsies and this increased to only 68% for autopsies on suspected or confirmed highly infectious remains.
T118 24421-24571 Sentence denotes Other higher level PPE such as a powered-air purifying respirator (increased by over 30%), Tyvek suit, HAZWOPER gear and SCBA also showed an increase.
T119 24572-24697 Sentence denotes A surgical mask was worn by 35% in standard autopsies and by 6% of ME/Cs for a suspected or confirmed highly infectious case.
T120 24698-24869 Sentence denotes Typically, at minimum an N95 is recommended for protection against aerosolized particles arising such as TB, Monkeypox, SARS and others, rather than a surgical mask [37] .
T121 24870-25206 Sentence denotes Additionally, an autopsy is inherently an aerosol-generating procedure, even organisms that might normally require only large droplet precautions (i.e. surgical mask) can be aerosolized at autopsy due to oscillating saws, aspirating hoses, etc. and thus require added respiratory precautions (i.e. N95 respirator or PAPR) [33, 38, 39] .
T122 25207-25387 Sentence denotes Use of a face shield rather than glasses/goggles also has been shown to reduce contamination of respirators by particles but only 59% of ME/C respondents routinely wear them [40] .
T123 25388-25621 Sentence denotes The following PPE changes occurred for suspected or highly infectious remains: the use of inner gloves, a face shield, and boot/shoe cover wear increased by 6%, 17%, and 7%, respectively, while donning eye protection decreased by 4%.
T124 25622-25757 Sentence denotes Usage of a N95 respirator increased by more than 15% and the use of a powered-air purifying respirator notably increased by nearly 30%.
T125 25758-25918 Sentence denotes Higher level PPE, such as a Tyvek suit, HAZWOPER gear and SCBA also were used when autopsies were performed on suspected or confirmed highly infectious remains.
T126 25919-26080 Sentence denotes Of concern, these results indicate ME/C alter their PPE based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach.
T127 26081-26234 Sentence denotes Despite some improvements in more protective ensembles in the suspected increased risk cases, the amount of training received by respondents was lacking.
T128 26235-26471 Sentence denotes Little more than half (56%) of respondents had received training on donning and doffing PPE in such scenarios, with the 61% of those who did have PPE training having spent an average of only 2 h or less per person per year on the topic.
T129 26472-26719 Sentence denotes Additionally, the entity that provided PPE training widely varied (e.g. in-house staff, affiliated university, safety and compliance departments), and no information was collected on the survey on the expertise level of those delivering trainings.
T130 26720-26854 Sentence denotes The lack of reproducible training time and variability of training entity suggest that more standardized training might be of benefit.
T131 26855-27330 Sentence denotes Designating a knowledgeable public organization to offer standardized training modules could lead to the following: (1) standardization of the organizational source of training; (2) content of training materials and modules based on reproducible, evidence-based best practices commonly found in the ME/C field; and (3) subscription to online training as it will likely be the most cost-effective and convenient means of training, as was proven successful in healthcare [41] .
T132 27331-27584 Sentence denotes Moreover, best practices and evidence-based studies have demonstrated that regular training for donning and doffing high level PPE in highly infectious scenarios provide substantially better occupational safety and health outcomes for the employee [6] .
T133 27585-27835 Sentence denotes In the event of suspected or confirmed highly infectious remains, most ME/C offices stated that the situation was handled on a case-by-case basis, depending on the pathogen that was suspected and required detailed conversations with all stakeholders.
T134 27836-27985 Sentence denotes As shown in Table 2 , procedures did vary between what would be performed with a suspected highly infectious body versus a confirmed infectious body.
T135 27986-28213 Sentence denotes In a confirmed case, all but one of the listed procedures as decreased compared to a suspected case (e.g. complete autopsy [27% decrease], washing or cleaning of the body [17% decrease], body storage in freezer [20% decrease]).
T136 28214-28427 Sentence denotes The only increase was, "bypass office and have body directly transported to funeral home/crematorium" by 21% which, as previously mentioned, may result in funeral home and crematory personnel being placed at risk.
T137 28428-28595 Sentence denotes Fewer than 50% of ME/C offices having been involved with handling a suspected or confirmed case, demonstrating a lack experience in handling highly infectious remains.
T138 28596-28877 Sentence denotes When asked which suspected or confirmed pathogens were encountered, however, many noted Category A or B pathogens (Table 4 ) [1, 2] that require specific deactivation and decontamination procedures-of which only approximately onethird (38%) of respondents had received training in.
T139 28878-29163 Sentence denotes It is possible that after such an event that the ME/C office would hire an appropriate contractor to conduct the appropriate deactivation and decontamination; however, the possibility remains [1, 2] that the task could go to individuals within the ME/C offices without proper training.
T140 29164-29290 Sentence denotes While most offices did not have a BSL-3 facility, nearly twothirds (60%) of those without a BSL-3 did have BSL-2 capabilities.
T141 29291-29513 Sentence denotes However, if 40% have only BSL-1 capability, then these morgues would essentially be considered appropriate for work only with agents not known to consistently cause disease in healthy human adults per CDC guidelines [42] .
T142 29514-29721 Sentence denotes In essence, a sizeable percentage of morgues in the U.S. are not equipped to safely perform autopsies on human remains with a large number of infections, especially those highly infectious disease autopsies.
T143 29722-29846 Sentence denotes In addition to improved training, more investment in morgue infrastructure would be necessary to enhance their capabilities.
T144 29847-30006 Sentence denotes Anecdotally, some larger ME/C offices have a computerized tomography (CT) scanner in which triple bagged sealed infectious remains can undergo virtual autopsy.
T145 30007-30114 Sentence denotes These bags can be constructed with portals to collect needed specimens for microbiologic/virologic studies.
T146 30115-30218 Sentence denotes The triple bagging prevents leaks and contamination and the remains can safely be sent to funeral home.
T147 30219-30436 Sentence denotes It would also be beneficial to have list of pathologists and support personnel in each ME/C office who could volunteer to take vaccines to handle certain cases with suspected contagious diseases (i.e. smallpox, etc.).
T148 30437-30572 Sentence denotes Approximately 20% of respondents reported that they did not examine suspected or confirmed highly infectious remains at their facility.
T149 30573-30640 Sentence denotes Given the lack of proper BSL facilities, this would be appropriate.
T150 30641-30860 Sentence denotes Slightly more than 20% noted the lack of space and/or a lack of staff in their offices as a limitation for being able to perform autopsies of suspected or confirmed highly infectious remains in a separate room or alone.
T151 30861-31122 Sentence denotes For biosafety, it is recommended that autopsy facilities should have a minimum of 12 air exchanges per hour, be negatively pressurized relative to surrounding office spaces, and exhaust air outside of the facility and away from areas of high pedestrian traffic.
T152 31123-31305 Sentence denotes Morgue laminar air flow should travel from clean to progressively less clean areas with downdraft table ventilation to decrease personnel exposure to aerosolized pathogens [32, 39] .
T153 31306-31433 Sentence denotes It is likely that significant financial investment would be required to retrofit many existing morgues to meet these standards.
T154 31434-31728 Sentence denotes Another option would be to have jurisdictional planning to transport suspected or confirmed cases to known centers that currently have the necessary BSL capability; again, body transportation would incur costs but likely lower costs than that associated with retrofitting many existing morgues.
T155 31729-32039 Sentence denotes In addition to improved morgue biosafety, it would also benefit ME/C facilities to have better publicized, easily accessed, and clearly laid-out protocols for various infectious scenarios in which limited autopsy (e.g. brain-only in suspected CJD cases) or no autopsy (e.g. EVD cases) is currently recommended.
T156 32040-32280 Sentence denotes When asked about level of training to handle and transport specimens for suspected highly infectious cases, only onethird of respondents had received this training with 20% spending on average less than 1 h per year per person on the topic.
T157 32281-32535 Sentence denotes Nearly half of respondents (47%) were unsure of what their jurisdiction permitted in the case of highly infectious remains for ultimate disposal, and alarmingly, 13% of respondents stated their jurisdiction permitted embalming and 15% traditional burial.
T158 32536-32805 Sentence denotes For EVD, for example, the recommended procedure is cremation to ensure complete deactivation of the virus in order to prevent spread to workers and the environment; those who were killed by the disease will have high viral loads present in their body post-mortem [43] .
T159 32806-33090 Sentence denotes While needs for funding, resources, supplies and appropriate capabilities may be universal across the death care sector, this survey's results strongly suggest that it would benefit state or regional-specific ME/Cs to have standardized education and training throughout the U.S [24] .
T160 33091-33312 Sentence denotes Likewise, open-ended comments from respondents indicated a need for augmented up-to-date formalized trainings, as well as revised written policies and procedures, and enhanced resources (including facilities and funding).
T161 33313-33620 Sentence denotes There were general perceptions of unpreparedness to address highly infectious remains, budgetary constraints and a weak national structure regarding autopsy biosafety, and a lack of incorporation of ME/C offices into infection control planning despite ME/C office involvement with highly infectious remains.
T162 33621-33658 Sentence denotes There were limitations to this study.
T163 33659-33768 Sentence denotes Because of the study's exploratory nature, the survey was not validated beyond subject matter expert vetting.
T164 33769-33946 Sentence denotes Additionally, the survey only included ME/C offices that served larger populations; smaller offices may still encounter HID cases if they do not outsource larger nearby offices.
T165 33947-34055 Sentence denotes Therefore, this study may not be generalizable to smaller offices (i.e. those serving populations <300,000).
T166 34056-34174 Sentence denotes Also, the survey instrument was designed to allow respondents to check multiple boxes when asked about the use of PPE.
T167 34175-34308 Sentence denotes The results, therefore, were not clear whether the respondent meant the PPE would be used simultaneously or one instead of the other.
T168 34309-34431 Sentence denotes For example, a face shield and respirator may be used simultaneously or a face shield may be used instead of a respirator.
T169 34432-34504 Sentence denotes Additionally, a limitation related to potential response bias may exist.
T170 34505-34720 Sentence denotes Although this study was not funded, there could have been sponsor bias on behalf of the respondents, as the survey was distributed by members of NAME, thereby potentially affecting the candidness of their responses.
T171 34721-35020 Sentence denotes Lastly, non-responses may have arisen because it would not appeal to prospective participants to take a survey about a topic for which they are not trained out of concern their answers may not be "correct." Nevertheless, this study addresses a critical gap about what is known and unknown about U.S.
T172 35021-35075 Sentence denotes ME/C capabilities to handle highly infectious remains.
T173 35076-35294 Sentence denotes In conclusion, this survey of U.S. medical examiners and coroners' capabilities to address highly infectious decedents presents opportunities for improvement at ME/C facilities serving their state or metropolitan area.
T174 35295-35840 Sentence denotes Standard operating procedures or guidelines (SOPs or SOGs) should be updated to take an all-hazards approach, best-practices on handling highly infectious remains could be integrated into a standardized education, evidence-based information on appropriate PPE selection could be integrated into a widely disseminated learning module, and existing relationships with the local health department, funeral homes and crematories could be bolstered to develop a multi-sectoral concept of operations for addressing suspected highly infectious remains.
T175 35841-36175 Sentence denotes While some issues will require greater capital and resources to address-such as retrofitting facilities to meet better biosafety recommendations, or more financial resources to enhance operation-the hope is that this study will draw attention to these more systemic issues and stimulate a call to action from the appropriate entities.
T176 36176-36178 Sentence denotes 1.
T177 36179-36183 Sentence denotes U.S.
T178 36184-36328 Sentence denotes Medical Examiners/Coroners play a critical role in death investigation, yet their capabilities to address highly infectious remains are unknown.
T179 36329-36363 Sentence denotes occupationally-acquired infection.
T180 36364-36366 Sentence denotes 3.
T181 36367-36563 Sentence denotes This survey, with respondents from nearly every U.S. state, revealed current levels of Medical Examiner/ Coroner training and education to address suspected or confirmed highly infectious remains.
T182 36564-36566 Sentence denotes 4.
T183 36567-36713 Sentence denotes Questions, and thereby results, focus on permissible autopsy procedures, personal protective equipment, and biosafety-level facility capabilities.
T184 36714-36716 Sentence denotes 5.
T185 36717-36917 Sentence denotes Medical Examiners/Coroners could benefit from updates to standard operating procedures and standardized education on handling suspected or highly infectious remains that taken an all-hazards approach.