How Early Did COVID-19 Actually Hit California? Full Picture May Never Come

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Cars drove down Market Street in San Francisco on January 22, 2020. Now, officials are trying to determine how early people began dying of COVID-19 in the United States. (Beth LaBerge/KQED)

Public health officials across California have begun a search to identify deaths from COVID-19 that occurred before widespread awareness of the disease. But the review could fall short because of inadequate state guidelines and stringent federal testing protocols, experts say, calling into question the effort to understand when and how the disease spread and how many people it killed.

Gov. Gavin Newsom called for a statewide review of deaths last month after the Centers for Disease Control and Prevention confirmed that the Feb. 6 death of a San Jose woman was the first known COVID-19 fatality in the United States. Patricia Dowd, 57, died a full month earlier than the Feb. 29 death of a Washington state man, previously believed to be the first U.S. fatality from the virus.

On April 22, the day after the CDC confirmed that Dowd had died from COVID-19, Newsom called on coroners and medical examiners across the state “to dig even deeper” into deaths that occurred as early as December “to ultimately help guide a deeper understanding of when this pandemic really started to impact Californians directly.”

Then on April 29, Dr. Sonia Angell, the state public health officer and director of the California Department of Public Health, issued the administration’s criteria for the review in a letter to county coroners and medical examiners, which stated: “The goal is to assess whether there were cases and deaths associated with COVID-19 in California during the pandemic at a time when testing was more limited and when wide community transmission of COVID-19 had not yet been recognized.”

Similar reviews of deaths are likely occurring all over the country, according to Dr. Sally Aiken, a medical examiner in Spokane, Washington, and president of the National Association of Medical Examiners.

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“We don't really know the full number of deaths because of limited post-mortem testing in some areas and we don't really know the denominator either,” Aiken said. “We don't know how many people have had COVID-19 infections, so that the actual mortality rate from COVID is unknown.”

Aiken said getting that data is crucial to understanding how to prevent more deaths.

As of May 18, 3,334 people are known to have died of COVID-19 in California.

Focus On Early Months of COVID-19 Spread

Angell, the California Department of Public Health director, instructed county officials to review death records for people who died between Dec. 17, 2019, two weeks before China officially identified COVID-19, and March 16, 2020, the date when six Bay Area counties implemented stay-at-home orders to slow the spread of the disease.

Angell told coroners and medical examiners in California’s 58 counties to look for cases where the cause of death was uncertain and the person had symptoms of the flu, viral pneumonia or acute respiratory distress, or a history of recent travel at the time of their death.

But the criteria she spelled out did not include several key symptoms that have come to be associated with the disease, according to Dr. Judy Melinek, a Bay Area independent forensic pathologist.

Patricia Dowd, the first known American to die of COVID-19, did not exhibit any of the symptoms on Angell’s list, according to Melinek, who reviewed the autopsy report of the woman’s death.

“She died of cardiac tamponade, which is a ruptured heart, and that's not on the search criteria,” Melinek said. “We wouldn't have even captured her using these guidelines.”

Melinek said the criteria should be expanded to include additional conditions and symptoms, including heart attacks, blood clots and a kind of body inflammation identified in some children with the virus.

“You're going to have to look for all of the symptoms, not just what we initially identified as the atypical pneumonia that COVID-19 was first described as,” Melinek said. “You have to look at all the potential things that it can cause.”

Decedents’ Tissue Samples and Swabs Could be Used to Test for COVID-19

Another challenge for county coroners and medical examiners seeking to identify previously overlooked deaths from the coronavirus is that their tissue sampling protocols don’t always align with the requirements of the CDC, which performs the post-mortem COVID-19 tests.

Santa Clara County’s medical examiner confirmed Dowd’s COVID-19 infection by submitting lung tissue, taken as part of the autopsy, to the CDC.

Even in cases where no autopsy is necessary, forensic pathologists will usually take some swabs and freeze them or preserve them. Those tissue samples can later be sent for testing, and that’s what officials are relying on to confirm previously overlooked COVID-19 deaths.

But in California, coroners and medical examiners in different counties can have differing policies on specimen and tissue collection – and they may not satisfy the CDC’s requirements.

For example, the CDC’s lab will not accept samples older than two weeks if they are submitted in formalin. But that mixture of water and formaldehyde is commonly used in California to store samples.

The State Won’t Review Most Deaths at Hospitals or Nursing Homes

Another weakness in California’s plan to identify earlier COVID-19 deaths is that it relies entirely on medical examiners and coroners to conduct the reviews. But those offices typically only handle unexpected, violent or sudden deaths that occur at home or in public.

Dowd died at home, so the Santa Clara County Office of the Medical Examiner-Coroner took jurisdiction of her case, performed an autopsy and sent tissue samples to the CDC to test for COVID-19.

But most of the confirmed COVID-19 deaths in California have occurred in hospitals and nursing homes. That suggests that earlier deaths that may have been due to the coronavirus likely took place in those settings as well.

By law, physicians at hospitals and nursing homes are supposed to report to the county medical examiner or coroner any death they suspect was caused by a contagious disease. But in the search for early COVID-19 deaths, the California Department of Public Health doesn’t plan to investigate whether they’ve done so. Instead, officials say they’re relying on hospital doctors to correctly report suspected coronavirus deaths.

“The focus of this effort is on unexplained deaths,” a Public Health Department spokesperson told KQED. “Medical examiners and coroners would typically be informed of deaths with an unknown cause, including those in hospitals.”

If a person died in a hospital or nursing home and their family members suspect the deceased person had COVID-19, survivors can ask doctors there to conduct a post-mortem test if tissue samples or swabs were taken. Relatives can also report their suspicions to the county’s coroner or medical examiner.

State to Update COVID-19 Count

Once medical examiners and coroners compile lists of suspected COVID-19 deaths, state officials have requested that they work with their county public health departments to prioritize which cases should be tested first.

Staff at the Los Angeles County Medical Examiner-Coroner department have been reviewing cases going back to December and determining whether they have tissue samples that can be submitted to the CDC, according to spokeswoman Sarah Ardalani.

“At this time, there are a handful of cases that might work, but we are still assessing testing feasibility,” Ardalani wrote in a May 12 email. “We are looking at which cases are appropriate for testing, including the consideration of relevant history, symptoms, and available specimens.”

Of the 1,839 known COVID-19 deaths in Los Angeles County, as of May 18, the medical examiner has identified 30 of them.

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If medical examiners and coroners discover additional people who died from the virus, they are expected to notify California’s Department of Public Health of a change to the person’s cause of death. The state will notify the CDC and the National Center for Health Statistics of any changes so those deaths are counted.