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THREAD: When did #COVID19 arrive in the United States? Recent reports out of Santa Clara County indicate that it came in early February: https://www.sfchronicle.com/health/article/First-known-U-S-coronavirus-death-occurred-on-15217316.php /1
I was recently asked to review two autopsy reports from Santa Clara County by the @sfchronicle https://www.sfchronicle.com/bayarea/article/Exclusive-Autopsy-report-of-first-known-15226422.php They were obtained via a public records request. /2
I also recently saw that @StanfordMed has published some data that indicates that in Santa Clara County “prevalence estimates represent a range ... 50- 85-fold more than the number of confirmed cases.”
https://www.medrxiv.org/content/10.1101/2020.04.14.20062463v1.full.pdf
https://www.medrxiv.org/content/10.1101/2020.04.14.20062463v1.full.pdf
Now, for full disclosure, I used to work in Santa Clara County as an Assistant Medical Examiner, and I have since worked in two other Bay Area Counties, so I know something about how death reporting works.
When a person comes into the hospital with a documented medical disease and dies, the death certificate is signed by the hospital clinician. If it is a natural death it is not reported to the medical examiner. We only get called if the death is sudden, violent, or unexpected.
We know now that #COVID19 disproportionately affects the elderly and people with pre-existing medical conditions. We know that the medical examiner in Santa Clara County went back retrospectively on cases from early February and found some that were infected.
And we know that the counts of infected cases were off by orders of magnitude due to a lack of testing and/or a lack of suspicion of community spread. We know that expected natural deaths in the elderly are not reported to the medical examiner - BUT These cases are captured...
They are captured by the death certificates (DCs) written by clinicians and reported to the medical examiners/coroners as “non-removals” or “no-cases” - cases where an infirm decedent with a pre-existing condition dies at home and the patient’s PMD agrees to sign the DC.
What needs to happen right now: every single county vital records system needs to look back into late 2019 - early 2020 (I would suggest going as far back as October 2019 (Wuhan reported their first case in November) and see if they have excess deaths compared to previous years.
This can be done right now and should be part of a national surveillance strategy in real time to see if we can pick up outbreaks or hot spots. @CDC can do this via the National Vital Statistics System. Individual ME/Coroners, Docs & Hospitals may not see trends...
But aggregate data can be more sensitive, especially for something like this: a virus that disproportionately targets the elderly, infirm and those with pre-existing conditions. I implore that @CDCgov and local Public Health Departments start looking back. @SF_DPH @AlamedaCounty
I think that there is a strong chance that the February 6 case in Santa Clara County is not actually the first one in the U.S. and there may be some in January or even December that were certified as “natural” deaths due to the decedent’s known pre-existing conditions.
