COVID-19 death toll includes patients who were never tested

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ILLINOIS (NEXSTAR) — As Illinois Public Health Department officials work to remove any inaccuracies from the state’s COVID-19 death count, the local departments compiling such data for IDPH are doing so without a uniform set of guidelines, a Target 3 investigation has found.

Emails and documents obtained via Freedom of Information Act requests by WCIA show coroners and medical examiners across the state have raised questions about the processes of classifying COVID-19’s role in an individual’s death, citing, in some cases, the difficulty of determining whether the novel coronavirus played a “probable” role in someone’s death or a “suspected” role.

In one case, a man who died after testing negative for COVID-19 was included in the state’s overall coronavirus death count.

IDPH director Dr. Ngozi Ezike has sought to reassure the public — including skeptics who believe that death toll is either lower or higher than it should be — that the state is eliminating “obvious” cases in which the virus did not play a role in a person’s death, regardless of whether they had tested positive for COVID-19.

“If there was a gunshot wound, an acute gunshot wound, if there was a motor vehicle accident — we know that was not related to the COVID-positive status,” she said. “There (are) also some additional deaths that happen in someone who happened to be COVID positive, but where COVID and COVID infection had nothing to do with the deaths.”

Dr. Ezike acknowledges there exists a “grey area” in which it becomes more difficult to determine the precise cause of death in COVID-positive patients who also have preexisting conditions when they contract the virus.

Around “90 percent” of COVID-19 deaths have had “an associated comorbidity,” she said last week, such as heart or kidney disease, diabetes, or chronic obstructive pulmonary disease. Other risk factors that could exacerbate the effect the virus has on an individual include age, whether a person has a compromised immune system, or cancer.

In those cases, she said, “it is obviously less clear that the COVID-19, the disease associated with the coronavirus didn’t actually play a part in the hastening of the death, so those deaths do stand.”

“Individuals who do test positive for COVID-19 and die with illnesses or complications caused by the illness are definitely COVID deaths and those continue to be counted in our count,” Dr. Ezike said.

As of Thursday, there have been nearly 4,000 such deaths across the state, according to IDPH.

Classifying COVID deaths

IDPH is relying on the expertise of doctors, coroners and medical examiners across the state to accurately classify the role COVID-19 plays in a person’s death, providing them general guidelines for this process outlined by the Centers for Disease Control and Prevention.

In most cases, a COVID-positive patient who dies does so in a hospital, long-term care facility or hospice, meaning a medical doctor is tasked with determining the cause of death.

“Typically, if the patient has been under the care of a doctor in a hospital, the doctor has had the opportunity to conduct various tests on the patient and obtain information as a consequence of those tests,” HSHS St. John’s Hospital pulmonologist Dr. Manjeshwar Prabhu said.

“So the doctor could potentially have an idea of the disease process the doctor is dealing with. And if, unfortunately, the patient succumbs to the illness, then the doctor can sign the death certificate saying that, ‘In the best knowledge that I have, this is what I believe to be the cause of death.’”

How does a doctor definitively know that a patient died from COVID-19?

“We don’t,” Dr. Prabhu said. “We don’t actually know that that patient died of coronavirus, which is why they’ve got a sort of sub-classification… a “COVID-related death” or that COVID was involved for some reason in that patient’s time.”

Urbana-based forensic pathologist Dr. Shiping Bao went a step further, saying that the responsibility of determining a patient’s death shouldn’t fall on the shoulders of hospital-based doctors who largely observe and monitor patient symptoms.

Those doctors, he said, “aren’t trained to certify the cause of death.”

“They have no idea how to determine the cause of death,” he said, adding that a forensic pathologist is better-suited for the task, which would likely involve a post-mortem examination.

“It becomes hard, once again, because we don’t have guidelines, right?” Dr. Prabhu said. “Nobody knows enough to give us clear guidelines. For example, you may have a patient who is on dialysis and is stable on dialysis, then they develop a COVID infection. And because they’re already weakened by the fact that their kidneys are not working properly, maybe this patient doesn’t survive and maybe they pass away. Could that be called death from renal failure with COVID-related? Probably. Or a physician might say that’s COVID infection — (the patient) just died of COVID.”

COVID on death certificates

A death certificate has three parts relating to why someone died: One which details the sequence of events that caused the death and includes underlying causes. Another section details “significant factors” that are not necessarily related directly to the cause of death but played noteworthy roles.

When asked by WCIA whether the state is breaking down how many deaths are directly tied to COVID-19 versus how many only cited COVID-19 as a contributing factor, spokesperson Melany Arnold did not specify, saying in an email that “IDPH counts deaths where COVID-19 is listed on the death certificate.”

The way that Vermilion County coroner Jane McFadden understands the process, as long as either a doctor or coroner “can directly relate that (death) to a strong possibility or probability of COVID, that would probably appear on the death certificate.”

Added Champaign County coroner Duane Northrup: “My understanding is that if somebody dies and they tested positive for COVID-19, obviously they know it was COVID-19 or that the person had it.
“‘Probable’ or ‘presumed’, if that’s listed on the death certificate, a lot of times that’s because the person had symptoms that were consistent with COVID-19, like a fever, cough, something like that that they’ve seen with COVID-19 patients but the person was not able to be tested before they died,” Northrup said. “So that death, if it was, say, from respiratory issues or something that’s commonly seen as a complication from COVID-19, (that was) listed as ‘probable’ or ‘presumed.’”

Coroners or death examiners become involved in COVID-related deaths when they happen outside of a hospital or other medical facility — like a person’s home — or when a person arrives to an emergency room already dead.

“Emergency room doctors don’t sign death certificates because they have no clue why the person died — they never spoke to them, they don’t have a history, they only get what they’re told by somebody who brings the person to a hospital via an ambulance, a family member or somebody,” McFadden said. “So that’s where we (coroners) come into play: The doctor doesn’t know and that falls on the coroner to investigate.”

While that work involves digging up a person’s medical history, contacting their primary doctors, and collecting enough evidence to determine a cause, the determination is ultimately a professional’s “best opinion.”

“It’s their best opinion of what that person died from because we don’t always know,” Northrup said. “You’re never going to know 100 percent, you know, necessarily without an autopsy or something like that.”

Even autopsies are limited to largely serving as a way to “rule out just as much as it’s used as an alternative determination (of death),” he added.

“Even with an autopsy, you might not know,” McFadden said. “You can have an autopsy and still not have a cause of death.”

Mistaken COVID case

A coroner or doctor’s “best opinion” isn’t always without error.

Emails between McLean County coroner Kathleen Yoder and McLean County Public Health’s communicable disease supervisor Melissa Graven and obtained by WCIA via a Freedom of Information Act request indicated a discussion about classifying a particular death as “probable COVID”; Yoder later told WCIA in an interview that the county had counted a man’s death as COVID-related, only to find out later the man had never contracted the virus.

“This person that I put ‘probable COVID’ — not as the first line (cause of death) but as the second line (significant factor) — was acute respiratory distress syndrome,” Yoder said. “So per my forensic pathologist (Dr. Scott Denton) and myself, we have to look at all the symptoms of COVID and then the chest X-ray demonstrated ground-glass opacity, which were indicative of COVID. We discussed this. And he was the one who wrote down ‘probable COVID’ and said, ‘This is what I would go with.’”

Denton could not be reached for comment on Thursday.

The man’s death has been included among IDPH’s total COVID-19 death count, Yoder said.

Missing COVID cases

In Champaign County, one death may still be outstanding from the county’s overall count of seven: In late March, Northrup requested guidance from the state on how to classify an early-February death that could be COVID-related.

“The patient’s diagnosis at autopsy was pneumonia-related, but we’re questioning whether it possibly could be related to COVID-19, based on some other circumstances,” Northrup said in an interview with WCIA. “I believe we will be able to get tissue samples tested at the CDC, but… it’s kind of complicated because there’s so much testing going on locally on (a)live people…that trying to get testing done on decedents is not necessarily a priority. I think we can get it done, it’s just not being done routinely on deceased patients.”

‘We are trying to be accurate’

McFadden understands that people in her position are under increasing scrutiny from the public, with rumors swirling “on social media and things like that” that coroners like her or medical doctors in hospitals were purposefully padding COVID-19 death numbers.

“We would rather not have deaths from COVID-19,” she said. “We want to be careful when we do label people — that somebody’s death is directly attributable to this disease because it’s just like any other death. We want to be as accurate as possible because other things depend upon what we put on that death certificate for families, per see. We’re trying to be as accurate as possible.”

Dr. Prabhu also pushed back against a notion circulating on social media that somehow COVID-19 deaths are less tragic — or the virus is less of a danger to the public at large — because the fatalities are most common among the sick or elderly.   

SOURCE: Illinois Department of Public Heath

“Yeah, people do say that, but you need to understand what the person’s quality of life was before they fell sick,” he explained. “80 or 85 is no longer considered the age beyond the line. Many people 80 or 85 lead very healthy, very active lives. I, in fact, have patients over the age of 90 who lead active lives who are clearly alive and who have desires that they want to do, like you know, I want to my grandson’s graduation, I want to see my great-grandson. They have desires and so such people clearly are entitled to the finest healthcare that we can provide.”

Even if medical experts don’t definitively know how patients who have COVID-19 died or precisely what the cause of death is, they know one thing: people are dying and the novel coronavirus plays a major role in those deaths.

“Things happen — we don’t fully understand what the virus is doing, and why it’s doing to certain people,” Dr. Prabhu said. “But anybody who feels that this is an insignificant threat — the threat is definitely significant. There is no question about that.”

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