300 post-mortems are the cornerstone of a new Danish coronavirus project

How can we prepare as well as possible for the next pandemic?

The question is almost unbearable in the midst of all the death and misery humanity is currently suffering due to COVID-19. Nevertheless, it is a relevant question. Experience has shown that there is always another pandemic to follow the one that has just run its course.

Therefore, we might as well be as thoroughly prepared as possible, and the deceased can help us with this in ways unmatchable by studies of the living. For instance, they can reveal how a truly aggressive case of COVID-19 ravages the lungs of patients – or attacks the brain, heart and other organs.

The unique knowledge a post-mortem can provide about COVID-19 will be collected under the auspices of a Danish project, with funding from the Lundbeck Foundation.

‘We’ll conduct 300 post-mortems in all, and the first three have already been performed,’ says Jytte Banner, professor and state-appointed forensic pathologist at the Section of Forensic Medicine, University of Copenhagen.

Professor Banner is heading the project and the team also includes pathologists from the departments of forensic medicine at the University of Southern Denmark and Aarhus University as well as from the departments of pathology at Rigshospitalet, University of Copenhagen, Odense University Hospital and Aarhus University Hospital.

‘A good many of the 300 post-mortem examinations will be performed on patients who had been hospitalised and were suffering from varying degrees of COVID-19 when they died. But there’ll also be post-mortems on patients whose COVID-19 status was unknown on their deaths – and, last but not least, there’ll be a number of post-mortems on people who were found dead and brought into the three departments of forensic medicine,’ explains Professor Niels Lynnerup, head of the Section of Forensic Medicine at the University of Copenhagen, who designed and planned the research project together with Professor Banner.

Consent will be obtained from the relatives for the post-mortem examinations, based on the same legal principles that govern post-mortems in non-coronavirus times.
However, Professor Banner explains that since the research project also draws on CPR-based (Danish civil registration number) medical journals – in order to identify any health details of potential relevance in a COVID-19 context – permission must also be sought from the Danish Research Ethics Committee:

‘And the results we publish afterwards will be completely anonymised. No relatives will be able to recognise details linked to a deceased family member.’

Organs in the scanner
Even the most experienced medical professionals are surprised and alarmed when they first see how quickly and severely coronavirus can damage an individual’s health – and the understanding of the disease that these clinical observations can provide is of significant help in attempting to save patients.

‘The post-mortems come into the picture because they give unique opportunities to study in more detail how COVID-19 works and can destroy an individual’s health. And the 300 examinations will actually attempt to provide new knowledge in quite a wide range of areas,’ Professor Banner explains.

Among other things, they will seek answers to the following questions:
*What damage does COVID-19 do to the lungs, heart, brain and other soft tissue, and what are the changes it causes?
*At what rate does COVID-19 damage the body – and what is the most common pathology?
*How does COVID-19 progress, from a mild case to a fatal case?
*Are there different strains of COVID-19?
*Do you need to have certain bacterial flora in your lungs to die of the disease?

The research team will conduct some of the required microbiological studies with colleagues from Statens Serum Institut (SSI) – for instance, regarding the question of the number of COVID-19 strains and whether there is a correlation between bacterial flora in the lungs and the risk of dying of the disease.

Other studies will rely on biological and chemical analyses conducted at the three departments of forensic medicine. One of the things they will investigate here is whether some drugs aggravate the symptoms of COVID-19 – as it is suspected that some anti-hypertension drugs do.

In the case of all 300 post-mortems, a full-body scan – or CT scan – will be performed before the actual examination begins. Professor Banner explains:

‘This has been part of our forensic post-mortem procedure for some years now, and there are several reasons for this. Firstly, it gives us a general picture and a good sense of which strategy could be most appropriate for the post-mortem in question. In the case of forensic post-mortems, a full-body CT scan can give information about a variety of changes such as bullet path, blade path and fractures. But the scan will also show signs of changes, for example, in lungs, that may be an indication of COVID-19 – and this, in itself, can be useful information. Particularly, if the deceased was not tested for the infection.’

Once the post-mortem examination is over – that is, the body has been opened up and the relevant organs removed – another scan is performed. This time, it is an MRI scan and this is where they look for possible COVID-19 damage and changes to soft tissue in the heart, lungs and brain.
They also take a range of samples of tissue, blood and urine, not to mention ocular fluid, which can be very useful for certain types of chemical analysis.
As soon as the organs have been scanned, they are replaced in the body, which is then neatly sewn up, and the samples are frozen for subsequent analysis.

Professor Jytte Banner explains that the conditions identified by the pathologists in the post-mortem examinations of the 300 Danes should provide new knowledge that can be applied to medical treatment of COVID-19 patients.

‘So, you can say that the dead are helping the clinicians. And we also hope to acquire new knowledge that could prove to be valuable when the next pandemic strikes. For example, we could gain a better understanding of how to contain infection and how to define risk groups more precisely.’