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The death cluster that could rewrite the history of COVID-19 in the US

“And I said, ‘I don’t know.'”

The sudden January death of Jeremiah DeLap, 39, is among cases now considered for COVID-19 testing.

The sudden January death of Jeremiah DeLap, 39, is among cases now considered for COVID-19 testing.

She still doesn’t.

Preserved samples of DeLap’s lungs are among tissue from more than 40 California deaths waiting for a decision by the US Centres for Disease Control and Prevention on whether to test for COVID-19. Orange County has nine of the cases, as does Los Angeles County. Kern County has identified two respiratory deaths that might suggest COVID-19, both of young women, one of whom died on December 21.

Interviews and internal documents show medical examiners in Shasta, Sacramento and Santa Clara counties, meanwhile, are scrutinising the deaths of children and babies, amid growing recognition of COVID-19 infection rates in children who show mysterious inflammatory symptoms.

A positive finding in any of the cases could dramatically rewrite the narrative of COVID-19 in the United States.

Researchers tracking the virus’ genetic mutations peg its jump from an unknown animal host to humans as occurring in November. China’s first documented illnesses began in early December.

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It was well into March before most California coroners and medical examiners began to routinely test decedents who fell under their jurisdiction for COVID-19, using now-familiar nasal swab tests that must be done within days of death. Even then, testing is limited to a fraction of cases – those who had symptoms of respiratory failure, travelled to China or died without witness.

Checking for missed cases of COVID-19 requires examining preserved tissue, a test available only through the CDC. It took months for CDC pathologists to realise the virus had already killed people in the United States in early February. At the time, US health officials believed they could control the virus spread by monitoring international travellers and isolating a dozen known infected individuals in California and four other states.

DeLap, 39, worked as a house painter in Basalt, Colorado, near the Aspen ski area. He returned to his inland Riverside County hometown for Christmas, and was at the home of his roommate’s parents in nearby Orange County on January 3 when he became sick. He thought the cause was something he ate the night before.

“He was having trouble breathing and I told him he should try and go to the urgent care,” Cortez said. “He told me he’d talk to me later and he went and [lay] down.”

He was found dead in bed hours later, his lungs filled with fluid and his body still burning from fever.

The Orange County coroner ruled DeLap’s death the result of severe acute lobar pneumonia, one lung so congested it had doubled in weight. But the coroner did not identify the organism infecting DeLap. The thought that it might have been the coronavirus haunted Cortez as she heard story after story of similar deaths. DeLap was an organ donor, so four weeks ago Cortez called the organisation that received his tissue to ask if they would test it for COVID-19.

Unknown to Cortez, the Orange County coroner harboured similar questions. DeLap’s death is among nine cases from late December to March the county has asked the California Department of Public Health to consider. The deceased range in age from 33 to 61, and include an elderly homeless man found in his campervan and a surfer who collapsed. Initial autopsies attributed their deaths to congested lungs, pneumonia or blood clots.

If the state agency agrees, the cases will be forwarded to the CDC for more review before preserved tissue is tested for COVID-19. Los Angeles County’s medical examiner has forwarded nine cases for review but county lawyers blocked the release of details.

The CDC is limiting California to just eight to 10 test cases a week.

The CDC is limiting California to just eight to 10 test cases a week.Credit:Bloomberg

After the CDC confirmed a Silicon Valley tech worker’s death on February 6 as the US’s first known COVID-19 fatality, Newsom called on medical examiners statewide to hunt for missed cases extending back to mid-December.

But the CDC is limiting California – a state of 39 million people – to just eight to 10 cases a week. The state health department has stepped in as a gatekeeper between county morgues and the federal lab.

Such restrictions did not exist before the COVID-19 pandemic. They are new to Dr Deirdre Amaro, the Shasta County sheriff’s forensic pathologist who relies on the CDC lab for infectious disease analysis when someone dies inexplicably in her rugged, deeply forested Northern California county.

People wearing protective masks walk down the stairs on Pier 39 in San Francisco, California. The state recorded a jump in reported cases this week.

People wearing protective masks walk down the stairs on Pier 39 in San Francisco, California. The state recorded a jump in reported cases this week.Credit:Bloomberg

Amaro was jolted this winter by the back-to-back deaths of two children, one an infant, and local accounts of other sick children. She called a January 29 meeting with county health and hospital officials. She remembers someone in the room theorising that it was a “bad year” for respiratory syncytial virus, usually referred to as RSV. It is a common childhood disease that seldom kills.

“Since I’ve been here … we have never had sequential cases that are paediatric deaths. I do NOT want to practice forensic pathology in a setting where that is the norm,” Amaro said. “The emotional/psychological toll is too great.”

She had already sent tissue from one of those paediatric deaths to the CDC for testing when the California health department set up hurdles. She has since sought virus testing for another paediatric death and is awaiting a decision on whether the CDC will accept the cases.

Early reports out of China and California suggested COVID-19 had very low infection rates among children.

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“What has emerged now, the experience we’ve had on the East Coast and in Europe has been markedly different,” said Dr Roberta Lynn DeBiasi, chief of the paediatric division at Children’s National Hospital in Washington and a co-author of several studies on COVID-19 and children.

DeBiasi is among researchers who in May began documenting growing numbers of hospitalised children with COVID-19 and symptoms normally associated with an otherwise rare inflammatory illness called Kawasaki disease. Some had high fever, joint pain and rashes. Others had abdominal pain. An alarming number show organ failure and heart damage, DeBiasi said.

Amid those reports, a California health department physician called Amaro, who in addition to her department’s own two deaths told her of others – two infants sent from Shasta County to hospitals in Sacramento.

Dr Chante Buntin, the state health department medical consultant, wrote to Sacramento County’s coroner expressing interest in infants and children who died with what might have been “COVID-like symptoms, Kawasaki-like symptoms in California during the period of December to present.”

Sacramento County’s coroner has sent a single case to the CDC for testing but would not provide further details.

California has no confirmed child deaths from COVID-19. The CDC in early April listed three suspected virus-related deaths of children nationwide, but has since not updated that information. The federal health agency has, however, alerted paediatricians to watch for signs of what it now calls “multisystem inflammatory syndrome in children,” or MIS-C.

The state Health Department’s press office defended the state’s reliance on the CDC and the federal agency’s 10-case weekly limit. Medical examiners in other states are not only testing many more dead, but using other methods such as postmortem testing for antibodies.

The state agency’s press office said the CDC testing is “highly specialised and requires careful validation.”

San Diego officials said that a review of more than 700 deaths turned up none that met the state’s written criteria – deaths from December 17 to March 16, with signs of respiratory failure, fever or cough, or known exposure to COVID-19 or international travel.

San Mateo County, a part of Silicon Valley home to California’s earliest COVID-19 cases, identified one suspect death.

According to agency emails, a county pathologist checked the freezer for tissue to send to the CDC, and discovered the samples had been “tossed” along with tissue from everyone else who died prior to March 11.

Los Angeles Times

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correction

In an earlier version of this Los Angeles Times article, Maribeth Cortez was erroneously referred to as Maribeth Ortiz.

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