Medical examiners in Washington state have had limited ability to look back at early deaths that may have been caused by undiagnosed novel coronavirus disease, even as retrospective testing elsewhere has set back the timeline for its spread in the country.

The earliest known COVID-19 deaths in the country, on Feb. 6 and Feb. 17,  were discovered months after they occurred, when a medical examiner was able to submit tissue samples taken during autopsies for testing. But few medical examiners and coroners’ offices in Washington state have taken a similar look back at deaths that occurred earlier this year, as counties have prioritized using resources to detect and contain current outbreaks.

“Almost certainly we missed cases. That’s a given,” said Snohomish County’s Chief Medical Examiner Dr. J. Matthew Lacy. “We almost certainly missed cases where people actually died of COVID because they were either reported to us early in the year, the symptoms weren’t given to us or they were symptomatic in a way that was ascribed to another disease.”

In King County, the medical examiner’s office has conducted more post-mortem testing than most. It has identified COVID-19 in dozens of bodies since it started viral testing of all bodies that came into its office in mid-April.

The office also sent some blood samples for testing and found that a woman who died Feb. 6 had antibodies against the disease at levels just below the cutoff for a positive test, said Associate Medical Examiner Nicole Yarid, who plans to have further testing done. Even if the woman didn’t die of the disease, Yarid said it’s valuable to know if there are signs of the virus in the woman’s tissue samples. Her office is also considering testing more cases retrospectively.

“It’s really important to make sure counts are accurate, including finding out when the first cases were and when this really started,” Yarid said. She said the chief medical examiner likes to use the adage, “You can’t manage what you don’t measure.”

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Retrospective testing can unlock information about COVID-19 and its spread, but it’s not possible in many cases. Medical examiners only take jurisdiction over a small number of natural deaths, such as deaths that seem unexpected or suspicious, or occasionally when someone dies at home. Only a portion of those result in autopsies, during which blood and tissue samples are taken. It’s impossible to test most people who died of symptoms similar to those of COVID-19 earlier this year, as they have been buried or cremated.

This has left some with unanswerable questions.

Geraldine Mowrey, who went by “Geri,” died at Good Samaritan Hospital in Puyallup on Feb. 13. The 85-year-old’s death certificate said she died of acute hypoxic respiratory failure and multilobar pneumonia, which have been commonly seen in people who die of COVID-19.

Her husband of 32 years, Paul Mowrey, said Geri had fought off bouts of aspiration pneumonia in the past and was recovering at Life Care Center of South Hill when she got sick a week before her release date. Geri had used an oxygen mask overnight in the past, but this time, she wasn’t able to breathe on her own and deteriorated rapidly, he said.

It was months prior to the facility reporting its first positive COVID-19 test result to the state, and Paul said he knows it may not be likely Geri died of COVID-19. But he can’t help but wonder.

“I go back and forth hoping it was and hoping it wasn’t. Was, so I can understand it and know why it happened so quickly,” he said. “Wasn’t, because who wants to be the first in the state to die of something?”

Geraldine Mowrey, who went by Geri, died on Feb. 13. Her husband, Paul Mowrey, said he can’t help but wonder if undiagnosed COVID-19 played a role in her death. (Photo courtesy of Paul Mowrey)
Geraldine Mowrey, who went by Geri, died on Feb. 13. Her husband, Paul Mowrey, said he can’t help but wonder if undiagnosed COVID-19 played a role in her death. (Photo courtesy of Paul Mowrey)

“We just won’t ever know”

Numbers from the Washington State Department of Health (DOH) grabbed headlines last month, when officials said they were reviewing about 3,000 deaths this year from causes similar to COVID-19.

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But it’s not likely that most of these deaths — from pneumonia, acute respiratory distress syndrome and hypoxia — are related to the disease, said Katie Hutchinson, a DOH health statistics manager.

A team of U.S. Centers for Disease Control and Prevention researchers found that community transmission of COVID-19 likely began in late January or early February but was limited.

“It’s clearly not possible to follow up on all 3,000 deaths,” Hutchinson said, as there aren’t blood or tissue samples available in most cases. “Nor would we want to, because it’s not uncommon over the course of the year for people to die of these conditions.”

The state’s review is mostly focused on analyzing data to see how many deaths may be missing from official counts. Research on “excess deaths” — the number above what would typically be expected — show that Washington hasn’t seen the same spike that other states hit hard by the virus have. But those numbers don’t only show COVID-19 deaths, and they are affected by drops in other kinds of deaths during the pandemic-induced lockdown.

It’s likely that “we just won’t ever know” the true death toll of COVID-19, Hutchinson said. But state officials have reason to believe the current numbers are an undercount.

In addition to the issue of undiagnosed deaths, the state has also identified about 100 death certificates in which physicians listed COVID-19 as a cause, but there was no record of the deceased having a positive test in the state’s system. Those deaths do not appear in state numbers, which put the death toll at 1,153 through June 5.

Meanwhile, the state is working to remove a small number of deaths among people who had COVID-19 but likely did not die of it, including about five deaths from gunshot wounds.

Searching for missing deaths

After the earliest known COVID-19 death in the country was discovered in Santa Clara County, California, Gov. Gavin Newsom instructed medical examiners and coroners to look back at earlier deaths, although this directive was met largely with confusion.

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There’s been no similar widespread effort in Washington state, where the first known coronavirus deaths occurred Feb. 26. State officials are leaving the matter to counties.

“The focus so far has been on the living,” Clark County Medical Examiner Martha Burt said. “We haven’t gotten encouragement from the state or county to move forward to retrospective testing yet.”

Some medical examiners and coroners, such as those in Benton, Snohomish and Spokane counties, don’t believe they came across any suspicious deaths in the past. Lacy, the Snohomish medical examiner, said he’s confident he didn’t miss any caused by COVID-19 while conducting autopsies. The disease causes damage to tissues that is “just not subtle” when it kills someone, he said.

But Lacy said it’s likely there were missed cases among the deaths that his office didn’t take on or those that received only external exams from his office.

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“That’s true of any medical examiner or coroner office in December, January, early February, before we were asking about COVID-like symptoms, or assumed such symptoms were other natural infectious diseases,” said Sally Aiken, president of the National Association of Medical Examiners.

For Yakima County Coroner Jim Curtis, there are some cases he looks back on and wonders about. But his office doesn’t have samples to test, even if they could, he said.

“If they would have come in now, I would have tested them for COVID,” he said.

Some medical examiners are interested in retrospective testing but don’t have the resources. Lacy said his office has seen furloughs as well as additional demand for services because of the pandemic and a rise in opioid deaths.

Some offices lack the resources to even universally test. In counties including Benton, Pierce, Skagit, Spokane and Yakima, bodies are only tested if there are signs the person may have had COVID-19.

The King County Medical Examiner’s Office has been able to universally test bodies using “off-label” testing kits they created, which were approved by the state lab, Yarid said. It also tested nasal swabs from 27 people still in the morgue but found no positives, and in partnership with the University of Washington, tested samples from 39 people who died of pneunonia and respiratory causes going back to November.