Severe Acute Respiratory Syndrome Coronavirus 2 Surveillance in Decedents in a Large, Urban Medical Examiner’s Office

  1. Andrew F Brouwer
  2. Jeffrey L Myers
  3. Emily T Martin
  4. Kristine E Konopka
  5. Adam S Lauring
  6. Marisa C Eisenberg
  7. Paul R Lephart
  8. Teresa Nguyen
  9. Andrea Jaworski
  10. Carl J Schmidt

Reviewed by

Read the full article See related articles

Listed in

Log in to save this article

Abstract

Background

Given the challenges in implementing widespread testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there is increasing interest in alternative surveillance strategies.

Methods

We tested nasopharyngeal swabs from 1094 decedents in the Wayne County Medical Examiner’s Office for SARS-CoV-2. All decedents were assessed using a coronavirus disease 2019 (COVID-19) checklist, and decedents flagged using the checklist (298) were preferentially tested. A random sample of decedents not flagged using the checklist were also tested (796). We statistically analyzed the characteristics of decedents (age, sex, race, and manner of death), differentiating between those flagged using the checklist and not and between those SARS-CoV-2–positive and not.

Results

A larger percentage of decedents overall were male (70% vs 48%) and black (55% vs 36%) compared with the catchment population. Seven-day average percent positivity among flagged decedents closely matched the trajectory of percent positivity in the catchment population, particularly during the peak of the outbreak (March and April 2020). After a lull in May to mid-June, new positive tests in late June coincided with increased case detection in the catchment. We found large racial disparities in test results; SARS-CoV-2–positive decedents were substantially more likely to be black than SARS-CoV-2–negative decedents (82% vs 51%). SARS-CoV-2–positive decedents were also more likely to be older and to have died of natural causes, including of COVID-19 disease.

Conclusions

Disease surveillance through medical examiners and coroners could supplement other forms of surveillance and serve as a possible early outbreak warning sign.

Article activity feed

  1. ScreenIT

    SciScore for 10.1101/2020.08.03.20162883: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variableWe determined the characteristics of the decedent population, specifically age (not available for 2 decedents); sex (female, male); race (Black, White, or Other/Unknown); manner of death (natural (cardiovascular), natural (other), accident, homicide/suicide, or pending/indeterminant); and SARS-CoV-2 status (negative, positive, invalid/inconclusive).

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    However, there are general limitations to the use of medical examiner data for epidemiological surveillance [20-22]. First, the population of decedents entering a medical examiner’s office may not be representative of the catchment population. Here, a higher percentage of decedents were male and black than the catchment population, reflecting entrenched institutional and sociocultural pressures resulting in a higher likelihood of a cause of death that would fall within the medical examiner’s purview. Any surveillance program will need to recognize the limitations caused by the skewed population. A second limitation of surveillance from medical examiner’s offices is that autopsies are apt to reveal medical conditions that would not have been detected while the decedent was alive. From the point of view of SARS-CoV-2 surveillance, detection of infections that were not clinically detected during life offers an opportunity to better understand atypical or asymptomatic presentations of the disease (particularly when the cause of death is unrelated to the infection) and to detect increased community transmission prior to large increases in symptomatic cases. Because of the limitations of decedent surveillance, it has largely been used only in small, targeted studies, such as those looking for underreporting of disease related to occupational exposure (e.g., silicosis [23]). Arguably, the potential of decedent disease surveillance has been underappreciated. While its limitations mak...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. NCRC

    Our take

    This study, available as a preprint and not yet peer reviewed, described how the Wayne County Medical Examiner office (WCMEO) in Michigan implemented a surveillance strategy testing 821 decedents (i.e. deceased persons) for SARS-CoV-2 infection. Testing took place from March 16 to July 10, 2020 through nasopharyngeal swabs. Overall, 8.8% tested positive for SARS-CoV-2, and Black race and older age (above 40 years in the study) were associated with a positive test result. Among suspected cases, 20% tested positive, while among randomly selected cases not suspected to be associated with COVID-19, 5% tested positive. As testing decedents in a medical examiner’s office may be a means to supplement existing surveillance data, it may not reliably reflect infection rates for a given catchment area, but may offer insights into COVID-19 associated deaths that were not previously identified.

    Study design

    cross-sectional

    Study population and setting

    The Wayne County Medical Examiner office (WCMEO) serving Wayne and Monroe countries in Michigan, piloted a surveillance strategy in which they tested 821 decedents (i.e. deceased persons) for SARS-CoV-2 infection. Decedents were flagged to be tested if they had one or more of the following: probable or confirmed COVID-19 diagnosis, symptoms (e.g. fever, shortness of breath, sneezing, coughing, chest pain, or body aches), recent travel, or contacts with probable or confirmed COVID-19 diagnosis or symptoms. WCMEO staff also tested randomly selected decedents who were not flagged. Testing took place from March 16 to July 10, 2020 through nasopharyngeal swabs. Investigators compared the socio-demographics between those who tested positive and those who did not as well as compared flagged decedents vs. non-flagged decedents.

    Summary of main findings

    Among 821 decedents tested, 230 (28%) were flagged by the COVID-19 checklist and 591 (72%) were randomly selected. The mean age among all decedents was 46. Overall, 72/821 (8.8%) tested positive for SARS-CoV-2. Those who tested positive for SARS-CoV-2 were older (mean age 53 vs. 45 among negatives, p<0.001) and Black (89% vs. 51% among negatives, p<0.001). Those who were flagged to be tested were also older on average compared to decedents who were not flagged (mean age 49 vs. 45, respectively, p<0.001). Decedents flagged by the COVID-19 checklist were more likely (20% vs. 5%, p<0.001) to test positive for SARS-CoV-2.

    Study strengths

    A strength of this study is that the method of testing decedents for SARS-CoV-2 infection is a means to document cases that were asymptomatic.

    Limitations

    The authors try to make the case that this tool could be a potential “early warning sign” for an outbreak if it is used to supplement other forms of surveillance; however, this is unlikely to be the case as infections such as SARS-CoV-2 and influenza may already spread to epidemic levels by the time cases are documented among decedents given the known lags between rising cases and deaths. Finally, it is unclear if the cause of death for any of these decedents was due to SARS-CoV-2 infection directly as most of those who were positive had a manner of death listed as “natural, other”. The sensitivity of PCR testing to identify SARS-CoV-2 viral RNA postmortem is uncertain, so it is possible that some true deaths from COVID-19 may have been missed with postmortem testing.

    Value added

    This study is one of the first to test decedents as a means of SARS-CoV-2 surveillance.

  3. Version published to 10.1093/cid/ciaa1312
  4. Version published to 10.1101/2020.08.03.20162883v1 on medRxiv