U.S. Medical Examiner/Coroner capability to handle highly infectious decedents.

"Conflict of interest None of the authors have any conflicts of interest to disclose."

"We would like to extend our gratitude to the members of the National Association of Medical Examiners (NAME) Ad Hoc committee for Bioterrorism and Infectious Disease for their support of this research and distribution of the survey; these members include: second author Erin Brooks (Chair), Paul Chui, Karen Kelly, John Matthew Lacy, Micheline Lubin, Lakshmanan Sathyavagiswaran, Leah Schuppener, Suzanne Utley-Bobak, and Steven White. Additionally, we acknowledge the National Institute of Environmental Health Sciences (NIEHS) Worker Training Program (WTP) Ebola Biosafety and Infectious Disease Response Training UH4 Information, grant number UH4 5ES027055. While the grant funding did not contribute to the development and distribution of this gap analysis survey, the program did highlight the need to explore research in this area. Lastly, we also thank from the University of Nebraska Medical Center: Elizabeth Beam and at Harvard T.H. Chan School of Public Health: Paul Biddinger for their partnership and support. There were limitations to this study. Because of the study’s exploratory nature, the survey was not validated beyond subject matter expert vetting. 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. Therefore, this study may not be generalizable to smaller offices (i.e. those serving populations <300,000). Also, the survey instrument was designed to allow respondents to check multiple boxes when asked about the use of PPE. The results, therefore, were not clear whether the respondent meant the PPE would be used simultaneously or one instead of the other. For example, a face shield and respirator may be used simultaneously or a face shield may be used instead of a respirator. Additionally, a limitation related to potential response bias may exist. 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. 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. ME/C capabilities to handle highly infectious remains. Compliance with ethical standards: Conflict of interestNone of the authors have any conflicts of interest to disclose.: Ethical approvalThis study was deemed exempt by Indiana University Institutional Review Board (Protocol #1711094822).: Informed consentSurvey participants were informed of potential risks and benefits prior to taking the voluntary survey. This informed consent survey was reviewed by the Institutional Review Board and approved as part of the exemption in the aforementioned protocol number."