Michigan ranks third in the nation with 2,093 deaths associated with coronavirus COVID-19, but that total doesn’t tell a complete story.

Medical experts agree the death count isn’t completely accurate. Where they disagree is whether the state’s real death toll from the pandemic is higher or lower than what’s been reported.

At least 2,093 Michiganders have died over the last 30 days, though some more accurately “died with COVID-19” than “died of COVID-19," according to medical examiners from some of the state’s most populated counties.

“I think a lot of clinicians are putting that condition (COVID-19) on death certificates when it might not be accurate because they died with coronavirus and not of coronavirus,” said Macomb County Chief Medical Examiner Daniel Spitz. “Are they entirely accurate? No. Are people dying of it? Absolutely. Are people dying of other things and coronavirus is maybe getting credit? Yeah, probably.”

Michigan doesn’t have a uniform process for testing individuals who die outside of hospitals and before they can be tested for the virus. Medical examiners, who investigate unnatural and unexpected deaths, are responsible for determining how those individuals died and who to test.

Some medical examiners are testing every body that comes through their office. Others are limiting tests to those who were symptomatic before death.

Between at-home deaths, asymptomatic patients and a lack of widespread testing, some health officials believe the death toll from the virus could be higher than what’s been reported.

“The reported total is probably a little low,” said Lynn Sutfin, communications director for the Department of Health and Human Services. “There probably are some out there who weren’t tested. Not outrageously low ... but there are some being missed who aren’t being counted.”

‘Deaths with coronavirus’ boost total

In Macomb County, Chief Medical Examiner Daniel Spitz had a recent case in which an individual died by suicide.

Because they had a family member in the hospital suffering from COVID-19, Spitz had a postmortem test done and found that the individual who died at home was positive for COVID-19. The virus wasn’t their cause of death, but the individual is counted as a COVID-19 death.

Similar cases of “death with coronavirus” have likely been included in the state’s count. In Oakland County, every individual who has died while infected with COVID-19 has counted as a coronavirus death, according to Dr. Ljubisa J. Gragovic, the county’s chief medical examiner.

“We are testing all the people who are deceased who are brought in, whether they sustained injuries or were in a hospital setting or their place of work or home, whether they’re victims of violence or unexpected sudden death, we’re testing them," Dragovic said.

Oakland County has 5,576 confirmed cases of COVID-19 and 392 reported deaths. Dragovic said his office began testing everyone a few weeks ago when testing materials became more readily available. He’s gotten “virtually one or two positives back a day.”

Dragovic doesn’t believe he’s alone in testing at a higher rate. He’s heard of medical examiners across the country who are testing as consistently as he is. But with the busy workload and limited staff working from their offices, there hasn’t been time to communicate how each office is handling the crisis statewide.

State Rep. Triston Cole, R-Mancelona, said he’s been concerned that the state is inflating its death totals to justify Gov. Gretchen Whitmer’s executive orders, which have disrupted much of the state’s economy and everyday life in an effort to reduce the spread of the virus and keep health care systems from being overwhelmed.

Cole said his questions to state health officials about the accuracy of the death total have gone unanswered.

“I think the numbers are being confused on purpose,” he said. “I don’t want this to be confused with me not taking the virus seriously though. Social distancing, washing your hands and wearing a mask in public are still an absolute must.”

Death is ‘often under-reported’ for infectious disease

In most COVID-19 deaths, patients test positive for the virus and receive treatment at a hospital before dying, according to the National Association of Medical Examiners. Coronavirus patients with underlying health conditions are more susceptible to serious cases.

However, there are cases where individuals die at home before they can be tested for COVID-19. In those cases, Michigan leans on medical examiners to investigate the deaths with the help of law enforcement and public health officials.

In places like Macomb and Kent counties, testing for the virus by the medical examiner’s office is only conducted if the investigation into the cause of death revealed an individual showed symptoms of the virus before dying.

“With any infectious disease, death can often be under-reported,” said Emily Toth Martin, an epidemiologist and associate professor at the University of Michigan School of Public Health.

“If you aren’t going to a hospital or going into care before passing, there is a lower chance you’ll be tested. The other thing to think about is not everyone that dies from an infection has classic symptoms that indicate they needed to be tested.”

Health officials believe as many as 25 to 50 percent of people with COVID-19 might not show symptoms, according to the Centers for Disease Control and Prevention.

Macomb County’s medical examiner said they’ve had a lot of their postmortem tests come back positive, though some have been negative. His office isn’t testing on a daily basis.

In Kent County, Chief Medical Examiner Dr. Stephen Cohle has had two county residents tested postmortem and one Northern Michigan resident whose body was sent to his office. All three tested negative for COVID-19.

Cohle said he would test every body that came into his office if county health officials asked him to. That hasn’t been the case thus far, and he said testing those who didn’t show symptoms would be “wasteful” in his opinion.

A positive COVID-19 test from a patient who clearly died from another cause would also not warrant another tally in the state’s COVID-19 death count, he said.

“You should mention COVID-19 on the death certificate but you shouldn’t certify it’s due to COVID if they died in a crash,” Cohle said. “That’s dying with COVID, not of COVID ... It defeats the point of having statistics.”

More data is best

Whether Michigan’s death toll is higher or lower than reported, Martin said looking at death counts is a simple way to look at the impact of a virus and if infections are going up or down.

Death counts allow epidemiologists to determine who is most at risk for serious cases, and to help find who should be prioritized for vaccination once one is available.

Martin said getting an accurate death count or infection timeline is challenging, however. Patients can die without reporting symptoms, and some may die weeks after being infected.

“With influenza, people might die of a heart attack and they might have had influenza but they might not have had influenza symptoms to suggest testing them,” Martin said. “It makes us rely on other indicators like the number of people who are symptomatic or who test positive. That information has a lot less delay."

Dragovic sees “significant benefit" in calculating every case of COVID-19 in Oakland County, whether the virus was a factor in a death or not.

Ideally, every resident would be tested, he said. That data is crucial for those working in health departments who are studying the penetrability of the virus in communities, which would otherwise be unknown.

“This is how we all learn about the behavior of a virus and how to respond to it in future situations,” Dragovic said. “It’s better we know better how to handle it at a clinical level and level of prevention.

“It’s important to get any bit of information about this virus and its behaviors in a population to those who are working day and night in development of new ways to cure or prevent or completely eliminate the virus.”

In addition to death counts, the state is reporting other data health professionals find helpful. Things like confirmed cases, recovered cases, positive and negative tests, and hospitalizations.

Spitz, Macomb County’s medical examiner, said counting the virus’ death toll isn’t an exact science. It’ll take future analysis from epidemiologists to determine the actual number of deaths and the death rate.

“We can’t know the death rate, we haven’t tested everyone,” he said. “If you don’t have total cases, you can’t be totally sure how many are dying.

“All the numbers have some value, it just depends how you interpret them. The more data we can put together, the more helpful it will be.”

CORONAVIRUS PREVENTION TIPS

In addition to washing hands regularly and not touching your face, officials recommend practicing social distancing, assuming anyone may be carrying the virus. Health officials say you should be staying at least 6 feet away from others and working from home, if possible. Carry hand sanitizer with you, and use disinfecting wipes or disinfecting spray cleaners on frequently-touched surfaces in your home ( door handles, faucets, countertops) and when you go into places like stores.

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