Mobile musician Wayman Henry died from COVID-19 three days before the state announced the first Mobile County death attributed to the novel coronavirus.

Fairhope retiree Tim Gaston died of the virus on March 27, according to the Baldwin County EMA, but as of 10 p.m. on April 1, the county was still listed as having zero deaths from coronavirus.

There were similar delays before the five patients who died of COVID-19 in less than two days at East Alabama Medical Center were added to the state’s official tally.

So why the wait? Dr. Karen Landers of the Alabama Department of Public Health says it takes some time to make sure it gets the number right.

“(ADPH) is concerned that deaths as a result of COVID-19 are reported accurately,” Landers said. “When a death occurs in a person who tested positive for COVID-19, the record is reviewed by an ADPH physician and other team members, as needed, to determine factors related to deaths and whether the death is attributable to COVID-19.”

That process has led to confusion and consternation when published reports of patient deaths exceed the numbers used by the health department on its public dashboard, tracking the spread of the disease in Alabama.

State Health Officer Dr. Scott Harris said at a press conference last week that the review of a COVID-19 death can even involve a physician or other staff member at ADPH calling and speaking to the doctors who treated the patient before making a determination.

ADPH spokesperson Arrol Sheehan said these investigations can take an hour or less once the department receives the patient’s medical records. Some investigations obviously take longer though.

“The reason it takes a few moments to get that information out is that we need to actually confirm that the death is related to COVID-19,” Harris said. “It’s certainly possible for someone to die of a different cause and yet perhaps they’ve had a positive test at some point and so we want to make sure we’re giving accurate information.”

The ADPH is the sole agency conducting these investigations in 66 of Alabama’s 67 counties and oversees the other.

The Jefferson County Department of Health conducts its own COVID-19 death investigations and submits those results to ADPH. Jefferson County reported its first COVID-19 death Wednesday morning and leads the state in confirmed cases with 305, as of Wednesday night.

The Mobile County Health Department, Alabama’s other independent county health department, is deferring to ADPH to investigate the deaths of its COVID-19 patients, according to MCHD epidemiologist Rendi Murphree.

“The state will make that determination,” Murphree said. “Jefferson County for example is doing their own. They had the bandwidth to do that, but we are totally fine letting ADPH physicians handle ours.”

For ADPH, the responsibility to investigate deaths comes on top of conducting the laboratory testing for COVID-19 samples collected from around the state, conducting follow-up interviews with patients who test positive and coordinating the state’s overall COVID response.

On Tuesday, the ADPH added a new metric to its COVID-19 dashboard: reported deaths.

This is the number of Alabama residents who have tested positive for COVID-19 and then died, for any reason. The department now shows this number in addition to the number of “died from illness,” which are the confirmed cases the department has investigated and determined that COVID was the cause of death.

As of Wednesday at 10 p.m., the dashboard showed 28 reported deaths of COVID patients and 17 confirmed COVID deaths.

Harris acknowledged the delays and discrepancies in numbers can be frustrating.

“It takes a little bit of time in public health for us to confirm exactly why a death occurred and we want to be accurate and make sure that we understand exactly what has occurred,” he said. “So sometimes those reports come out a little more slowly than we would like.”

What about patients who haven’t been tested?

Deciding whether a death was caused by coronavirus can take several days even when doctors know the patient has tested positive for COVID-19. If a patient dies without getting tested but has symptoms common in COVID-19 patients, a final determination may take even longer.

Harris said procedures are in place for determining whether a deceased patient may have had COVID.

“It’s certainly not necessary for a test to be done before someone dies,” Harris said. “Obviously that information would be helpful but there is a procedure for making the diagnosis postmortem, after someone has died.”

The U.S. Centers for Disease Control has issued guidelines for conducting postmortem COVID investigations for health professionals, showing how to safely collect samples from deceased patients, but says that medical examiners, coroners, and other healthcare professionals should “use their judgment” to determine if the tests are needed.

Murphree, who previously worked at the CDC, said in those cases the doctors would follow procedures that were previously established for deaths that might be related to influenza. She said if the patient was showing signs of COVID but hadn’t been tested, a sample would be collected and sent to ADPH for testing and then to the CDC for verification.

“Postmortem processing takes a long time,” Murphree said.

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