Shelby County Coroner Lina Evans believes COVID-19 was likely killing people this winter in her county before it was thought to be in Alabama.

“I feel pretty confident it was here. It was here before we knew it was here,” said Evans, who is also a hospital nurse.

Reflecting back on the winter, Evans says there was a surge in hospice deaths in her county, as she saw nearly double the roughly 125 from last year. Many of those who died were 65 and older. They died of ailments like acute respiratory failure, pneumonia, COPD and heart failure, causes of death now associated with coronavirus.

But coroners in other parts of the state did not report a similar uptick.

“Had the region had many unsuspected COVID-19 related illnesses and deaths prior to March 13, then the disease would have spread through the population more rapidly than it did,” said Medical Examiner Dr. Gregory Davis in Jefferson County.

Keeping an accurate track of the toll of the disease, even now, continues to present a challenge. Doctors in Alabama say they believe COVID-19 deaths may be undercounted despite awareness of the disease’s spread in Alabama, partly because of statewide issues with testing.

In Shelby County, home to affluent suburbs of Birmingham, Evans says she observed something similar as a hospital nurse where she treated people with some unusual respiratory illnesses this winter.

“They tested negative for flu, difficulty breathing, not responding well to traditional therapies,” she said. “They had COIVD symptoms but we didn’t know what was wrong with them.”

Evans speculates some elderly people in her county may have been infected with coronavirus from home health workers who travel from patient to patient.

“They go to multiple houses, and we didn’t know it, we didn’t know they were exposed.”

Hundreds of miles south, coroner Dr. Brian Pierce in Baldwin County is also reconsidering some strange deaths he documented this winter. Pierce says several young people, as young as 19, died at home from pneumonia after testing negative for the flu. He later learned they had diabetes.

Baldwin County sees year-round tourism from out of state as well as winter-time snowbirds traveling in and out.

“Looking back, we can’t confirm it, but we do have our suspicions that perhaps it was here back in December and January,” said Pierce, who says he worked about a quarter of the county’s total deaths last year.

But not all Alabama coroners share these suspicions. Dr. Tyler Berryhill is coroner in Madison County, home to Huntsville in north Alabama.

“On our small portion of cases that we had, we had maybe one or two that we’ll go back and do an additional review on,” he said, adding that his office only had two deaths this winter that might be suspicious if those individuals hadn’t tested positive for the flu. He says he has not reviewed hospice data from Madison County.

Jefferson County, the state’s most populous and home to Birmingham, did see hospice deaths from respiratory failure double during that period, from 16 in the first three months of 2019 to 33 in the same window in 2020. Overall hospice deaths were up 18.5 percent, from 432 to 512, for the same window in Jefferson County.

Davis says the numbers probably do not reflect COVID-19 deaths. “It is possible,” that some of the deaths were from COVID-19, but unlikely, he said.

He says the data could be skewed because different hospice companies report from year to year and the information they report is not as specific as that on a death certificate.

UAB Hospital Epidemiologist Rachael Lee, M.D., says pneumonia and respiratory deaths at the hospital were not out of the ordinary this winter. She says the Birmingham hospital consistently sent tests to the Alabama Department of Public Health in February and early March for patients with severe pneumonia and no identifiable cause or for patients with recent travel history, all of which were negative.

“I think we truly caught the very beginning of the virus’ arrival here in Alabama,” said Lee.

From an epidemiological or research standpoint, it’s not useful to consider respiratory-related deaths where testing for COVID-19 never occurred, said Assistant State Health Officer Dr. Karen Landers.

“We really cannot speculate,” about deaths from this winter without positive tests, she said.

In Alabama the rollout of coronavirus testing has been limited and delayed. As of Friday, 20,605 Alabamians had been tested for the disease and there were 2,999 confirmed cases, according to ADPH. Private labs are also testing for coronavirus, but they are only required to report positive cases, making it difficult to get a complete testing picture for the state.

“While, we want to have the most meticulous and most accurate data on deaths,” said Landers, “The most important message is ‘let’s do all we can to reduce the spread of the virus so we can prevent (more) deaths.’”