Theresa Freed 00:00
Hundreds of Johnson County residents have lost their lives to COVID-19. On this episode, learn how the cause of death is determined and find out how our medical examiner and public health offices work closely together in this pandemic.
Whether you live in or just love Johnson County, Kansas, JoCo on the Go has everything Johnson County. Here's what's happening and what's coming up in the community you call home.
Theresa Freed 00:27
Thanks for joining us for JoCo on the Go. I'm your host Theresa Freed, a Johnson County resident and employee of Johnson County government. Each week. You can tune in to a live broadcast on Facebook to get the latest on COVID-19 and vaccine distribution in our community. During a live news conference on Facebook. We sat down with the Johnson County Medical Examiner that's Dr. Diane Peterson and Johnson County Department of Health and Environment Director Dr. Sanmi Areola. And also JCDHE epidemiology director Elizabeth Holzschuh to discuss death investigations involving COVID-19. Here is some of that conversation.
Dr. Diane Peterson 01:05
Thank you. As you said, I am the chief medical examiner/coroner for Johnson County, it is my responsibility to sign death certificates of and investigate deaths of individuals who die in our jurisdiction, and especially those who die due to non-natural means, but also by state statute, it is my responsibility to review deaths of individuals who die from a disease that's a threat to public health, which includes COVID.
Dr. Sanmi Areola 01:40
Thank you, Dr. Peterson, for for joining us on Facebook Live, to be clear, in addition to what she described, like we say all the time, this is this has been a teamwork. Dr. Peterson, has been part of our conversations, part of our discussions throughout the process. So she really brings more, she adds more to this response than what she described so she's been part of our response behind the scenes, our most of the time with that tremendous knowledge a tremendous opportunity. But here's the deal quite often we, Dr. Peterson, we get these questions around the number of deaths. The I think I've heard the difference between dying from and dying with. And and I know that you have worked very closely with Elizabeth and our Epi team in ensuring that our death data are as accurate as they can. And I know that you have been very diligent you have been conducting tests yourself when doing autopsies and those details. So if we just take us through this past one year how that works and just educate us that that'll be that'll be very helpful to our listenership.
Dr. Diane Peterson 03:02
Sure. So if anybody passes away in Johnson County, and they, the hospital, the hospice agency suspects that COVID may have played a role or not, they will let us know when they report the death. So there are certain deaths that are required to be reported to my office, all deaths at home, are required if they're unattended. And all deaths that are due to non natural means. So in the beginning, we did notify the hospitals, that COVID is a reportable disease, and that that's due to COVID were required to be reported to our office. We also notified nursing homes and hospice agencies. And so anytime any of these individuals pass and COVID is suspected, either by their symptoms or they've had a positive test, then the case gets called into us. And we take the history we take the information, and most of the time, their natural deaths so the private physician can sign the death certificate. There have been some that as you've said, we've had to either test ourselves, my investigators who go out on scene, if while they're out on scene, the death scene, they get information that this person has had a fever, difficulty breathing, some of these symptoms of COVID but maybe haven't been tested for COVID then we are testing out on scene for COVID. If they have extensive medical history, then we will pass that the results of that test on to the physician Before they sign the death certificate, but some of them are unexpected deaths, some of them have been young individuals. And so we've had to bring them in. And we've had to do an autopsy, in addition to that COVID test to see exactly why they died. So, yes, we've been doing autopsies on COVID individuals, we've been testing COVID individuals, every single COVID death has been required to be reported to our office. And if it's not reported, we still see it in death certificate data. And anytime we see it on the death certificate, we relay it to the Epi team. So back to this question of dying "with" or "of" I think it's important to understand the death certificate. First, the death certificate has two parts. Part One, Part Two, Part One is a cause of death statement. It's that disease or condition that immediately leads to the death. And it's basically four lines, the immediate cause of death. And then it's a do to statement. So everything underneath of it is due to so this, the immediate cause is due to something which might be due to another thing. And all of all of those things get listed, if it's a due to statement. Part Two, are the contributing factors. These are diseases or conditions, which contributed significantly to the death, but did not immediately lead to the death. So let's think of a non COVID example. Part One might be a heart attack, which is a myocardial infarction, due to coronary artery disease. So the immediate cause of death was that heart attack, the reason that heart attack happened was the coronary artery disease. In that contributing factors, we might have diabetes, because diabetes increases the rate at which you develop the coronary artery disease. But it didn't cause the heart attack but in fact, it played a significant role. So when the CDC reports, all of these things listed on the death certificate, they are listing everything in Part One and Part Two, that's been listed on the death certificate. Because after I fill out a death certificate or any other physician, it goes to the state, and the state assigns a code to each line. And the CDC reports out those codes that correspond to all of those lines. And so anytime you see CDC data, it's lost that context, it's lost that due to statement, it's no longer in the proper order, you don't know where on the death certificate it was, was it part one, part two, you just know that it was on the death certificate. So it kind of loses a little bit of that context, when you look at the lists of reasons that people with COVID have had listed on their death certificates. So I'll give you an example of some COVID cases that we've had, where COVID might be in the cause of death statement, or it might be in the contributing factor. Either way, it's important to be included on the death certificate, anything that plays a role in the death, that you can say, but for this condition, this death would not have happened at this time. So if you cannot say, but for COVID, they would not have died, you need to put COVID on the death certificate. So with in the cause of death statement, things like pneumonia, COVID causes a very unique pneumonia under the microscope, cellular changes that COVID causes I've never seen in any other virus before. It's very unique changes. The cause of that statement for that might be COVID-19 pneumonia is what some people call it. It might be the specific changes that I'm seeing due to COVID 19 infection, and that would be in the cause of death statement. But a scenario where COVID might be a contributing factor is we had a case of a person who had a blood clot to the lungs. She had had COVID for about a week or so during that week. wasn't moving very much. And then developed a blood clot that went to the lungs and killed her. The cause of death is that blood clot to the lungs that's in the cause of death statement. But for the COVID, she would not have developed that blood clot. So COVID is a contributing factor, it did not immediately cause the death, the blood clot immediately caused that. But it played a significant role in the death. So it's a contributing factor. In that case,
Dr. Sanmi Areola 10:33
I'll just ask Elizabeth now. So quite often, in reporting those data, sometimes we've had to make some adjustments to those numbers, based on feedback from KDHE. We want to get into your interactions with Dr. Peterson's team, but also on how the data works. And over in reality, it takes a while for death data for a year, not calendar year, but the reporting period to be finalized if you want to get into some of those details.
Elizbeth Holzschuh 11:09
Absolutely. Thank you. Dr. Areola. Let me first just say that we are exceptionally privileged to have Dr. Peterson and her team here in Johnson County. You know, I think that of COVID-19 had broken out, you know, even two or three years ago, before we had our Office of the Medical Examiner, we would be in a very different situation, her team has been invaluable from the very beginning. And in talking to counterparts throughout the state of Kansas, they have run into significant issues, because they don't have that kind of working relationship with their coroner. You know, we used to be in the same building. So we know Dr. Peterson, we know her investigators. And so as soon as this began, we developed a very close working relationship where we were providing tests, we were, you know, having continual feedback about how to move forward and, and how this was going to look because this was a new experience for all of us. And so when Dr. Peterson's team identifies a death, that is likely due to COVID, they will send us an email, they send our team an email with the details of the death, the individual, whether or not there's a positive test already on record. And if they don't have one, but have been informed, for instance, from a family member that they tested, they will request that information from our team since we have that, and so will communicate about any kind of test results. Additionally, they also include information about what the physician is going to sign on the death certificate, as she said, the private physician unless there's some extenuating circumstances, will sign that death certificate. And that is not part of the M.E.'s role, the Office of the Medical Examiner's role. So they convey that information, you know, pneumonia due to COVID-19. So what we do on our end as the epidemiology team is we go into our disease surveillance system, and we mark that the individual died and the summary of death from Dr. Peterson's investigators. And we mark that, yes, the disease or the death was due to COVID. If that is what the physician is indicating, after that point, as Dr. Peterson said, the death certificate that the physician signs goes to KDHE, the Kansas Department of Health and Environment has an office of vital statistics. And there they review that death certificate and note whether or not COVID-19 was either a contributing cause, or a significant factor she described. Now if that, if the death certificate the official record does not include COVID-19, even if we had had initial information from the physician that they were going to sign it as such. So it's marked in there that yes, the death was due to COVID-19. And then he he gets that death certificate and COVID-19 is not listed, then their responsibility at KDHE is to go back into that system into that record, and say, nope, in fact, this was not due to COVID-19. And so when that happens, that's why you'll sometimes see our death count on our dashboard decrease. And honestly, usually KDHE does this in batches. So sometimes, you know, we'll be adding deaths as we go along. We want the data to be as accurate and as timely as possible. So if we've gotten that initial information from Dr. Peterson's investigators, or from Dr. Peterson that yes, it's due to COVID-19 we'll mark it but then, you know, maybe it's next month, when that death certificate is finally registered with the state. And they're doing their review. And so you might see if you'll even five or six, where the initial information said yes, and those final records said no. And so I think that even though it can cause some confusion as to why we are removing deaths from our death count, in my opinion, this is the system working right, we do want to have as accurate of account of the death associated with COVID as possible deaths that are due to COVID. And so this relationship that we have, enables that to be very timely, but sometimes, you know, for some reason we get the information from the physician that you have, they're gonna sign it as COVID-19 and then that final record does not have it and we have to go with whatever that final record has, is that is the official death certificate. So that's why you might see some fluctuations in the counts and sometimes we do remove a few But again, I think that that is that's the way infectious disease data works. As we get more information as we get those final records, we update that to portray as accurate of a picture as possible it,
Dr. Diane Peterson 15:11
it can go the other way. If we bring a person in, and we do a test, it can go the other way if the death was not reported to us, and then we see it when we're doing cremation permit reviews, and now we're adding it days after the death, because we're seeing it on that death certificate. And then there are some that make it all the way to the state before we find it out.
Jody Hanson 15:41
And do families play a role in this at all as far as what they want? The death certificate to say or not to say? And maybe not just in this situation? But in other situations? Is that a factor at all?
Dr. Diane Peterson 15:53
No, no. And that's the important factor of being in a medical examiner's office, we are independent, non-advocate, unbiased individuals who are filling out this death certificate, it is my job to say what I see and interpret what I see. So it is not up to the families of what gets put on the death certificate. Ultimately, it's up to that physician that's signing the death certificate. And the way in which the death certificate is signed is also up to that physician.
Elizbeth Holzschuh 16:36
And I will also say, you know, because of the world we're living in, there are people who, you know, have died due to COVID. And their family members maybe don't believe that it was due to COVID and whether it's because of some beliefs about COVID being not a thing or whatever that may be. And those death certificates do reflect that it was COVID-19 because again, that is independent of the family members wishes and is based on the science and what that the information available at the time of death.
Dr. Sanmi Areola 17:03
Yeah, we've got Dr. Peterson here. I know she wants to talk about why she does. So maybe we'll have a speak to the public about the need to get vaccinated.
Dr. Diane Peterson 17:12
Yes, absolutely. Please, continue to get vaccinated. It helps our caseload we were quite busy during the December, January. I remember on Christmas Day, we had at least 10 to 12 deaths just in that one day. And since people have started getting vaccinated, the death rate has dramatically decreased. We appreciate that our workload has decreased. We don't like to see that high death rate. So definitely continue. I one last thing, I guess, is the urban legend of if you're in a car accident, and you have COVID and COVID gets listed on the death certificate, it's just that it's an urban legend. That is not true. As I said before, a medical examiner is required to complete all non natural death certificates a private physician is not legally allowed to sign that death certificate. And I can tell you that there have been no traffic accidents in Johnson County, where I have listed COVID on the death certificate. So if you heard that from a friend of a friend, urban legend,
Theresa Freed 18:29
And be sure to follow us on Facebook so you know when we're live for the latest on the pandemic in the community and get much more on COVID-19 in Johnson County at jocogov.org/coronavirus. Thanks for listening.
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