With Postmortem Testing, 'Last Responders' Shed Light On Pandemic's Spread

As the coronavirus pandemic has unfolded, all eyes have been on the medical workers and public health disease detectives fighting on the front lines ― and sometimes giving their lives — to bring the coronavirus under control.

But as efforts to test for the coronavirus and trace cases continues, medical examiners and coroners play a vital — if often unsung ― role. These "last responders" are typically called on to investigate and determine the causes of deaths that are unexpected or unnatural, including deaths that occur at home.

In the early days of the outbreak, a scarcity of tests often hampered their efforts. Now, as that equipment gradually becomes more widely available, these professionals may be able to fill in answers about how people died and if those deaths were related to the coronavirus. And these confirmed cases can also help investigators trace contacts who may also be infected.

Those changes won't happen at once or uniformly across the country, experts predict. In addition, an increase in postmortem testing is likely to put coroners and medical examiners in the middle of a debate heating up about the true number of COVID-19 casualties.

Determining how many people the virus has killed is an ongoing bone of contention. Some defenders of the Trump administration's response charge that death estimates are inflated, often because they include people who were presumed to have died of the disease but not tested for it. Administration critics counter that the chaotic rollout of testing and treatment led to thousands of needless deaths that aren't represented in the official death toll.

Even now, months after the emergence of COVID-19 in the United States, the availability of test kits and testing materials, such as nasal swabs, remains inadequate in many places. Public health experts agree that broad-based testing is critical for people to safely emerge from lockdown and for businesses and other institutions to safely reopen.

"Some localities are prioritizing testing sick people over dead people, and that's probably a good decision if they have limited testing available," says Dr. Sally Aiken, the medical examiner for Spokane County, Washington, who is also president of the National Association of Medical Examiners.

As availability increases, however, stepping up postmortem COVID-19 testing could uncover important clues about the spread of the virus, experts say.

During the pandemic, many sick people have stayed at home and died there rather than seeking help at hospitals overwhelmed with coronavirus patients.

In April in New York City, for example, a reported 200 residents died at home each day, compared with 20 such deaths before the pandemic, a spokesperson for the city's medical examiner told WNYC, the local public radio station.

Tests were not possible in many of those instances. But with more tests, such cases are now getting attention.

"Most of the ones we test are the individuals who die at home," says Gary Watts, the coroner in Richland County, S.C., who is president of the International Association of Coroners and Medical Examiners.

If family or friends say the person had symptoms consistent with COVID-19, the coroner's office will typically do a nasal swab to test for the virus, he says. If the test is positive and the office can determine the cause of death without an autopsy, one will generally not be performed.

Coroners and medical examiners have similar responsibilities but their backgrounds are often different. Coroners are typically elected officials who may or may not have a medical degree. Medical examiners are typically medical doctors and may have a specialty in forensic pathology.

Like Watts, Dr. Kent Harshbarger, the coroner for Montgomery County, Ohio, which includes the city of Dayton, says his office now has enough tests to determine if COVID-19 was involved in suspect deaths, unlike during the pandemic's early days.

With more postmortem testing, "you can do better contact tracing," he says.

A few medical examiners and coroners are now stepping up testing significantly, performing tests on all the bodies that are brought in, says Aiken.

"They're surprised at some of the people who are positive," including suicides and car accidents, she says.

One reason for increasing testing is to protect the staff who are handling the bodies, says Dr. Judy Melinek, a forensic pathologist in the San Francisco area and CEO of PathologyExpert.

If a body at the morgue is positive for COVID-19, "you want to avoid doing an autopsy unless it's absolutely necessary," Melinek says, because of the risk of becoming exposed to the virus through aerosolized particles or blood. Plus, she noted, the Occupational Safety and Health Administration recommends against performing autopsies in COVID-19 deaths.

Even if coroners and medical examiners aren't doing extensive nasal-swab testing on the recently deceased, they can provide vital information later on, some note.

It's standard practice to take blood samples from patients who are sent to the morgue, and coroners and medical examiners typically keep blood samples on hand for up to a year. Testing those blood samples for antibodies to the coronavirus, which would indicate a prior infection, could give public health experts a clearer sense of when the virus arrived in the United States and the extent of its spread.

It won't identify every undiagnosed infection, since antibodies don't show up until one to three weeks after infection occurs, according to the federal Centers for Disease Control and Prevention. People may die before then. Still, postmortem antibody testing could provide useful information, experts say.

"If we can figure out when [the virus] arrived in the U.S., we can figure out a lot more about how this virus came through and was undetected," Melinek says.

Going forward, as public health experts and politicians contemplate decisions about reopening the country for business and the possibility of a resurgence of the virus, the more concrete information available the better, experts say.

"Postmortem testing is helpful and important when it is balanced by the logistical feasibility of doing it," says Lorna Thorpe, a professor of epidemiology at New York University Grossman School of Medicine. "When politics enters this space, it's nice to have confirmed cases so that it can't be critiqued."

Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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