Epistemic_Statements  

CORD-19:112d99dcf6554496b5dd4ce4696ff2850647388a JSONTXT 8 Projects

Annnotations TAB TSV DIC JSON TextAE

Id Subject Object Predicate Lexical cue
T1 126-413 Epistemic_statement 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.
T2 414-598 Epistemic_statement denotes This survey of U.S. ME/Cs′ capabilities to address highly infectious decedents aimed to determine opportunities for improvement at ME/C facilities serving a state or metropolitan area.
T3 658-836 Epistemic_statement 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.
T4 917-1127 Epistemic_statement 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.
T5 1128-1297 Epistemic_statement denotes Additionally, ME/ C altered their personal protective equipment based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach.
T6 1298-1765 Epistemic_statement 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.
T7 3604-3846 Epistemic_statement 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] .
T8 3847-4222 Epistemic_statement 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.
T9 4223-4411 Epistemic_statement 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] .
T10 4608-4812 Epistemic_statement 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.
T11 5227-5411 Epistemic_statement 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.
T12 5478-5759 Epistemic_statement 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] .
T13 6084-6297 Epistemic_statement 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] .
T14 6298-6482 Epistemic_statement 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] .
T15 6801-7197 Epistemic_statement 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] .
T16 7368-7555 Epistemic_statement 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.
T17 7556-7961 Epistemic_statement 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. ME/Cs to handle highly infectious remains.
T18 8508-8755 Epistemic_statement 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).
T19 9526-9798 Epistemic_statement 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.
T20 9799-9884 Epistemic_statement denotes All responses to questions were voluntary so response rates between questions varied.
T21 9885-10051 Epistemic_statement 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.
T22 11969-12129 Epistemic_statement 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) .
T23 12451-12530 Epistemic_statement denotes Four respondents stated their office would not perform autopsies on such cases.
T24 13438-13593 Epistemic_statement denotes In the event of suspected highly infectious remains, respondents were asked what procedures would be permissible and performed by their office ( Table 2 ).
T25 13594-13981 Epistemic_statement 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.
T26 13982-14129 Epistemic_statement denotes For comparison, respondents were asked which procedures or tasks would be performed in the event of confirmed highly infectious remains (Table 2) .
T27 14317-14449 Epistemic_statement denotes One respondent stated they would decline jurisdiction if no circumstance beyond the confirmed infectious disease made it reportable.
T28 15258-15438 Epistemic_statement 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.
T29 16871-16926 Epistemic_statement denotes This statement raises concern as the study by Le et al.
T30 16927-17183 Epistemic_statement denotes 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] .
T31 17600-17869 Epistemic_statement 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.
T32 18079-18160 Epistemic_statement denotes In addition to the sink for handwashing, there should also be an eyewash station.
T33 18161-18262 Epistemic_statement denotes All aerosol or splash-generating procedures should be performed in a biological safety cabinet (BSC).
T34 18263-18412 Epistemic_statement denotes There must be an autoclave or alternate method of decontamination for proper waste disposal, and the facility must have self-closing, lockable doors.
T35 18520-18545 Epistemic_statement denotes Biosafety Level-3 (BSL-3)
T36 18546-18781 Epistemic_statement 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.
T37 18848-18981 Epistemic_statement denotes In addition to all the aforementioned PPE, respirators may be worn and are required when experimentally infected animals are present.
T38 19031-19237 Epistemic_statement 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.
T39 20523-20753 Epistemic_statement 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.
T40 20971-21093 Epistemic_statement denotes 1 Survey respondents also had the opportunity to provide open-ended comments at the end of the survey; 26 respondents did.
T41 21094-21757 Epistemic_statement 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).
T42 21758-22061 Epistemic_statement 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.
T43 22062-22219 Epistemic_statement denotes As sudden unexpected deaths fall under Medical Examiner/ Coroner jurisdiction, they may play a fundamental role in the response to infectious disease deaths.
T44 22220-22519 Epistemic_statement 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.
T45 22874-22980 Epistemic_statement denotes ME/Cs frequently investigate deaths with little clinical information on the circumstances preceding death.
T46 22981-23225 Epistemic_statement 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.
T47 23226-23393 Epistemic_statement 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.
T48 23681-23888 Epistemic_statement 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.
T49 24698-24869 Epistemic_statement 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] .
T50 24870-25021 Epistemic_statement denotes Additionally, an autopsy is inherently an aerosol-generating procedure, even organisms that might normally require only large droplet precautions (i.e.
T51 25022-25114 Epistemic_statement denotes surgical mask) can be aerosolized at autopsy due to oscillating saws, aspirating hoses, etc.
T52 25207-25387 Epistemic_statement 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] .
T53 25919-26080 Epistemic_statement 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.
T54 26081-26234 Epistemic_statement denotes Despite some improvements in more protective ensembles in the suspected increased risk cases, the amount of training received by respondents was lacking.
T55 26720-26854 Epistemic_statement denotes The lack of reproducible training time and variability of training entity suggest that more standardized training might be of benefit.
T56 26855-27330 Epistemic_statement 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] .
T57 28214-28427 Epistemic_statement 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.
T58 28428-28595 Epistemic_statement 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.
T59 28596-28877 Epistemic_statement 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.
T60 28878-29163 Epistemic_statement 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.
T61 29291-29513 Epistemic_statement 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] .
T62 29722-29846 Epistemic_statement denotes In addition to improved training, more investment in morgue infrastructure would be necessary to enhance their capabilities.
T63 29847-30006 Epistemic_statement denotes Anecdotally, some larger ME/C offices have a computerized tomography (CT) scanner in which triple bagged sealed infectious remains can undergo virtual autopsy.
T64 30007-30114 Epistemic_statement denotes These bags can be constructed with portals to collect needed specimens for microbiologic/virologic studies.
T65 30115-30218 Epistemic_statement denotes The triple bagging prevents leaks and contamination and the remains can safely be sent to funeral home.
T66 30219-30419 Epistemic_statement 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.
T67 30573-30640 Epistemic_statement denotes Given the lack of proper BSL facilities, this would be appropriate.
T68 30641-30860 Epistemic_statement 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.
T69 30861-31122 Epistemic_statement 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.
T70 31123-31305 Epistemic_statement 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] .
T71 31306-31433 Epistemic_statement denotes It is likely that significant financial investment would be required to retrofit many existing morgues to meet these standards.
T72 31434-31728 Epistemic_statement 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.
T73 31729-31947 Epistemic_statement 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.
T74 32003-32039 Epistemic_statement denotes EVD cases) is currently recommended.
T75 32536-32805 Epistemic_statement 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] .
T76 32806-33090 Epistemic_statement 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] .
T77 33621-33658 Epistemic_statement denotes There were limitations to this study.
T78 33769-33946 Epistemic_statement 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.
T79 33947-34018 Epistemic_statement denotes Therefore, this study may not be generalizable to smaller offices (i.e.
T80 34175-34308 Epistemic_statement denotes The results, therefore, were not clear whether the respondent meant the PPE would be used simultaneously or one instead of the other.
T81 34309-34431 Epistemic_statement denotes For example, a face shield and respirator may be used simultaneously or a face shield may be used instead of a respirator.
T82 34432-34504 Epistemic_statement denotes Additionally, a limitation related to potential response bias may exist.
T83 34505-34720 Epistemic_statement 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.
T84 34721-34927 Epistemic_statement 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."
T85 34928-35075 Epistemic_statement denotes Nevertheless, this study addresses a critical gap about what is known and unknown about U.S. ME/C capabilities to handle highly infectious remains.
T86 35295-35840 Epistemic_statement 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.
T87 35841-36175 Epistemic_statement 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.
T88 36179-36328 Epistemic_statement denotes U.S. Medical Examiners/Coroners play a critical role in death investigation, yet their capabilities to address highly infectious remains are unknown.
T89 36567-36713 Epistemic_statement denotes Questions, and thereby results, focus on permissible autopsy procedures, personal protective equipment, and biosafety-level facility capabilities.
T90 36717-36917 Epistemic_statement 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.