Officially, COVID-19 has killed well over 100,000 people in the United States. But weekly mortality data also released by the Centers for Disease Control and Prevention (CDC) recorded at least 20,000 “excess” deaths from Jan. 1 to April 25 not accounted for by COVID-19. What caused these additional deaths?
While some non-COVID-19 deaths are likely a result of the pandemic’s wide-ranging indirect impacts, including patients delaying care for other medical conditions, most experts agree that many are dying from COVID-19 without being diagnosed.
Testing the bodies of people who died in the community of possible infectious symptoms or unexplained causes has been a cornerstone of the response to Ebola virus disease outbreaks, including to the recent outbreaks in West Africa and the Democratic Republic of the Congo. The World Health Organization and governments of affected countries set up systems to report any fever-related illnesses or deaths. Blood samples or oral swabs were collected from symptomatic individuals as well as from the deceased. This effort uncovered new Ebola outbreaks that could then be contained.
A similar approach should be instituted in the United States for the coronavirus: The CDC should direct the states to swab and test people who died for COVID-19 if the infection status is unknown. Currently, to our knowledge, no state has uniform standards for postmortem coronavirus testing.
An important result is that hidden hot spots of the virus could be revealed. Postmortem testing has already reshaped our understanding of how, where and when the disease first took root in the country. Researchers initially believed the earliest coronavirus deaths in the United States were on Feb. 26 and Feb. 29 in the Seattle area, but two individuals in California who died on Feb. 6 and Feb. 17 were later found on autopsy to test positive.
Identifying such hidden clusters of infection is increasingly important, as all 50 states have now begun to relax social-distancing measures and allow economies to reopen.
Doctors and public-health experts are concerned that increased social interactions may trigger a second surge of infections and deaths. Testing and rapid identification of cases among both the living and the deceased would guide contact tracing and targeted containment measures to help prevent a resurgence.
Routine testing of the deceased could also help explain the suspiciously large increase in at-home deaths in localities hard hit by the pandemic. New York City experienced perhaps the most shocking rise, hitting 200 a day in early April, compared with 20 or 25 daily at-home deaths before the pandemic.
Postmortem testing could also provide a more accurate understanding of the virus’ impact and fatality rate among different demographic groups. According to an analysis of national data, mortality among Black Americans from COVID-19 is 2.4 times that of white Americans. How would a more comprehensive accounting of coronavirus deaths shape this picture?
The CDC already provides guidance for how to collect and submit samples from deceased individuals for COVID-19 testing, often only requiring a nasal swab. While exceptions could be made perhaps for some causes of death, such as accidents, testing should be thorough, given the increasing evidence that the coronavirus may attack many different organs, resulting in deaths that can look like those from other causes, such as a stroke or heart attack.
Mandated testing of the deceased should be covered as part of the government’s pandemic response, and costs would be modest. Testing all those who died in Washington state in the week ending April 25, for example, would have amounted to less than a 4% increase in the total number of tests done that week statewide.
While expanding testing of symptomatic and at-risk individuals remains central in managing the pandemic, testing the deceased can reveal valuable information to protect the living, as it did during the Ebola outbreak. It can also play an important role in providing closure and clarity for families.