7.6 Deaths from Infectious Causes and Public Health Reporting

7.6 Deaths from Infectious Causes and Public Health Reporting

ABMDI places deaths from infectious causes with masqueraded, media-sensitive, and animal deaths under Investigating Atypical Death Scenes. The label makes sense: an infectious death is atypical not because infection is rare but because these deaths present as something else — a sudden collapse, an unattended death, a suspected overdose — and because they carry an occupational hazard that no other case type does.

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Recognizing It at the Scene

Infectious deaths reach the office disguised. The recognition comes from the scene and the history, not from appearance.

History indicators: a febrile prodrome in the preceding days; cough, dyspnea, vomiting, or diarrhea; headache with neck stiffness; a rash, particularly a rapidly spreading purpuric one; recent travel, especially international; occupational exposure in healthcare, agriculture, or animal handling; animal or arthropod exposure including bats, rodents, ticks, and livestock; injection drug use; and immunosuppression from disease or therapy.

Environmental indicators: congregate living — shelters, dormitories, correctional facilities, long-term care; unsheltered living; overcrowded housing; rodent infestation and droppings; standing water; and evidence of a household cluster where more than one person is ill.

Medication indicators are among the most useful things at a scene. Antituberculosis therapy (isoniazid, rifampin, pyrazinamide, ethambutol), antiretrovirals, immunosuppressants and biologics, recently dispensed antibiotics, and antifungals all tell you something the decedent could not.

Specific patterns worth knowing:

• Meningococcal disease — rapid onset, fever, and a purpuric or petechial rash, progressing to purpura fulminans with adrenal hemorrhage in the Waterhouse-Friderichsen syndrome. This is the classic exposure-notification emergency because close contacts require prophylaxis within hours.
• Tuberculosis — chronic cough, weight loss, night sweats, congregate or unsheltered living, and often an undiagnosed decedent. Aerosol risk at autopsy is substantial.
• Hantavirus pulmonary syndrome — rodent exposure, a brief prodrome, then fulminant pulmonary edema.
• Rabies — animal or bat exposure weeks to months earlier, encephalitis, hydrophobia; NAME classifies vector-borne disease deaths, including rabies, as natural.
• Prion disease — rapidly progressive dementia, myoclonus, ataxia; requires specific handling because prions resist routine decontamination.
• Viral hemorrhagic fever and novel respiratory pathogens — travel history plus fever is the trigger; suspicion alone changes handling immediately.
• Sepsis from an occult source — decubitus ulcers, injection sites, dental infection, retained foreign bodies, untreated diabetes with an infected extremity.

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Handling and Personal Protection

Standard precautions apply to every case; infectious suspicion escalates them.

• Respiratory protection at minimum a fit-tested N95, and a powered air-purifying respirator where available, for suspected tuberculosis, novel respiratory pathogens, and any aerosol-generating procedure
• Autopsy in a negative-pressure suite with appropriate air exchange where the facility has one
• Restrict aerosol-generating steps. The oscillating saw is the principal aerosol generator in the morgue; a vacuum-attached saw, a hand saw, or a saw used inside a containment bag reduces the risk substantially
• Limit personnel in the room to those necessary, and exclude observers and students from high-risk cases
• Sharps discipline — no hand passing of blades, no recapping, cut-resistant gloves
• Body bag labeling and transport notification, so that transport staff, the funeral home, and the embalmer are informed of the hazard rather than discovering it
• Prion protocols are distinct and stringent: dedicated instruments, specific decontamination, and often a decision to limit or forgo autopsy after consultation

Where the risk is high enough, the correct answer may be no autopsy, or an external examination with postmortem imaging and targeted needle or limited sampling, decided jointly by the pathologist, the office administration, and public health.

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Specimens and the Overgrowth Problem

Postmortem blood cultures are difficult to interpret. Bacteria translocate from the gastrointestinal tract agonally and after death, so a positive postmortem culture may reflect contamination rather than the fatal infection. Mitigating practices include culturing early, sampling from multiple sites, using a peripheral vessel and a solid organ such as spleen rather than heart blood alone, and interpreting results only alongside histology, which shows whether there was a tissue response, and molecular or immunohistochemical confirmation.

A useful specimen set for a suspected infectious death:

Formalin-fixed tissue matters more than candidates expect, because the CDC Infectious Diseases Pathology Branch performs specialized immunohistochemical and molecular testing on fixed tissue for unexplained deaths with suspected infectious etiology. That means a case can be resolved months later from paraffin blocks if the sampling was thorough — and cannot be resolved at all if it was not. Consultation and submission are coordinated through the state health department.

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Notification Duties

Public health reporting is a statutory obligation, and the reportable-condition list is set by the state. Reportable infectious deaths, and particularly any suspected case of a high-consequence pathogen, are reported immediately by telephone rather than through routine paperwork, because the public health response is measured in hours.

Exposure notification for responders has a federal framework. Part G of the Ryan White HIV/AIDS Treatment Extension Act of 2009 provides for notification of emergency response employees who may have been exposed to a potentially life-threatening infectious disease while responding to or transporting a victim of an emergency. NIOSH maintains the list of covered diseases and the guidelines describing exposure circumstances, and the process runs through a designated officer for the responding agency, who submits or receives notification requests involving the medical facility to which the victim was transported. For an ME/C office the practical points are: know who your agency's designated officer is, document exposures at the time they occur, and ensure that police, fire, and EMS who handled the decedent are told when a hazard is identified.

Downstream notification is equally important and is frequently forgotten: transport staff, the funeral home, and the embalmer handle the body after the office does, and they are entitled to know.

Where deliberate release is suspected — an unusual pathogen, a cluster with no epidemiological link, an unexpected presentation such as inhalational anthrax — notification runs to the FBI and to public health simultaneously, and specimens are routed into the Laboratory Response Network rather than to a routine clinical laboratory.

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The Office as Sentinel

Medical examiner and coroner offices see the deaths that never reached medical care: the unsheltered decedent with undiagnosed tuberculosis, the child with fulminant meningococcemia who died before transport, the cluster of deaths in a single building. That vantage point makes the office an outbreak sentinel, and several outbreaks have been recognized first in a morgue.

Realizing that value requires three habits: sample well even when the diagnosis seems obvious, because retained fixed tissue is what makes retrospective testing possible; report quickly, because the public health value of the information decays within days; and look across cases, because the signal in an outbreak is a pattern among decedents who arrived separately and were worked by different investigators. A senior investigator who reviews the week's cases as a set is performing surveillance, whether or not anyone calls it that.