The deaths, spread out across four states in January 2020, have become part of a scattershot collection of clues about the virus’s early spread.
Late last year, the federal government’s chief statistician on death received word about a tantalizing discovery: Someone had died from Covid-19 in January 2020, a death certificate said, a revelation that would have sped up the timeline of the virus’s spread in the United States by several weeks.
That death was ultimately not what it seemed. The person who certified it had meant June 2020, not January. But that blip on the radar screen of Robert Anderson, the chief of mortality statistics at a branch of the Centers for Disease Control and Prevention, helped to kick off a quiet, yearlong campaign at the agency to check and recheck the country’s first suspected Covid-related deaths in the uncertain days of early 2020.
Now, at least four possible Covid-19 deaths from January 2020 have survived Dr. Anderson’s vetting. Spread out across four states, they have become part of a scattershot collection of clues about the virus’s early spread beyond China — some of them trustworthy, others less so — that have begun drawing more attention as scientists and intelligence officials try to unravel how the pandemic began.
The odds that all four of the C.D.C.’s new death cases — from Kansas, California, Alabama and Wisconsin — really did result from Covid-19 are slim, some scientists said. This year, a doctor or another official certifier reclassified them as being Covid-related. But whether they did so solely on the basis of the person’s symptoms, or with the help of more useful blood or tissue samples, is not clear.
The earliest death, on Jan. 9, 2020, in Kansas, was reclassified this spring on the basis of the person’s symptoms alone, the state health department said, putting the onus on a doctor to evaluate how closely the patient’s disease matched the symptoms of Covid-19. The most common symptoms of the virus, including a fever, difficulty breathing and even a loss of taste or smell, overlap with symptoms of other respiratory illnesses.
In a sign of how difficult it can be to recategorize long-ago deaths, C.D.C. records include a fifth Covid-related death from January 2020, in Oklahoma. But after state officials investigated, the medical examiner removed Covid-19 from the death certificate, Oklahoma’s health department said on Wednesday, meaning that it will probably soon fall off of the C.D.C.’s records, too.
It is not clear whether any of the suspected cases had traveled to China.
“My guess is that they’re probably not all real, maybe not even any of them,” said Michael Worobey, an evolutionary biologist at the University of Arizona. It’s highly unlikely that any of the people caught the virus in the United States, he said, but it’s possible that some had recently been to China. “If any of them are real, they’d be travel-linked cases, and that’s conceivable,” he said.
Dr. Worobey’s research, including close analyses of viral genomes and epidemic simulations, has indicated that the virus was unlikely to be spreading outside of China before mid-December 2019, making non-traveler deaths in the United States the following month doubtful, he said. Several weeks typically pass between someone getting infected and dying, and any given case is unlikely to be fatal.
“Extraordinary claims require extraordinary evidence,” Dr. Worobey said.
For Dr. Anderson, the trustworthiness of the January 2020 deaths is not only a public health concern, but also a personal preoccupation.
A demographer by training who landed at the C.D.C. in 1996 after staring down a treacherous academic job market, Dr. Anderson said that certain deaths had an outsize impact, statistically speaking. And that includes Covid deaths early in the pandemic.
When states submit Covid-19 death numbers, the C.D.C. normally takes them at face value, as it does for hundreds of thousands of deaths from heart disease or cancer any given year. The agency recorded nearly three million registered deaths in 2019, and a mistake here or there does not change the country’s overall picture of mortality, Dr. Anderson said.
Not so for a possible Covid death at the dawn of a pandemic. At the time, testing was scarce. Until The Mercury News in California recently reported on the possible cases from January 2020, the earliest suspected Covid-related fatality was not until Feb. 6, 2020.
When Dr. Anderson is notified of Covid-related deaths from the first two months of 2020, he calls state health officials, who in turn ask for verification from the doctor or medical examiner who signed the death certificate.
In January of this year, for instance, the C.D.C. received a flurry of reports of people having died from Covid-19 in January 2020. Or so they said. Further checking revealed that most doctors had simply forgotten to start writing 2021 next to their signatures.
In another case this summer, Dr. Anderson confirmed that a medical certifier had meant to reclassify a January 2020 death as Covid-related, only for that certifier to backtrack once the state health department intervened.
Looming over the drudgery, for Dr. Anderson, is a single death from 2007 that the agency had said was caused by diphtheria, a serious bacterial infection that is virtually unheard-of in the United States. The C.D.C. later determined that the death had not been caused by diphtheria at all; a simple coding error was to blame.
“That was a little embarrassing to have in our data file,” Dr. Anderson said. “Even though it’s just one death, in that context, it has a big impact, because it’s high-profile.”
Ultimately, though, without access to patient samples or medical records, the C.D.C. has to trust the people who sign Covid-19 death certificates, he said.
“I can’t say for sure these are all accurate,” Dr. Anderson said of the January 2020 deaths. “But I think it unlikely that certifiers would have capriciously changed the death certificate.”
Most Covid-19 deaths are straightforward to certify, said Marcus Nashelsky, a professor of pathology at the University of Iowa who helped the C.D.C. write guidelines about how to attribute such deaths. For example, early in the pandemic, when nursing home patients were not always being tested, he said, a known outbreak in the home, in combination with characteristic symptoms and signs of the virus, could be enough for a doctor to declare a Covid-related death.
Nevertheless, death certificates have become hotly contested documents during the pandemic. In some cases, disbelieving families have asked that someone’s death certificate be wiped of any mention of Covid-19, said James Gill, Connecticut’s chief medical examiner and the president of the National Association of Medical Examiners. In others, families have urged that Covid-19 be added to a death certificate, seemingly in an effort to become eligible for funeral funding under a federal assistance program, he said.
“It’s a very emotional thing for some families, whether or not they want it on the death certificate,” Dr. Gill said. “It shouldn’t be. It’s a public health matter.”
In spring 2020, Dr. Gill said, he became concerned that Connecticut was overlooking Covid-19 deaths, especially among nursing home residents whose complicated medical histories can sometimes obscure causes of death. In a few hundred cases, he said, the medical examiner’s office conducted deep nasal swabs on bodies at funeral homes. The team found a number of cases.
With China refusing to share more information about its own early cases, the World Health Organization recently said that it was helping researchers dig into reports of cases in late 2019 outside of China. In Italy, researchers have reported coronavirus antibodies in blood samples from September 2019, as well as signs of the virus in a patient’s skin sample from November of that year. Some scientists, though, have questioned both findings.
“The further back you can go, the more informative it may be — if you do have true, confirmed cases,” said Marion Koopmans, a Dutch virologist whose lab retested the Italian blood samples and could not confirm the earliest cases. She added, “For declaring a much earlier introduction of the pandemic virus into a region, you have to have a high level of certainty.”
An analysis of American blood tests published this summer suggested that the virus may have been circulating in Illinois as early as Dec. 24, 2019, though scientists have said that those methods, too, are fallible.
Keri Althoff, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health and lead author of that study, said that small clusters of cases could have developed without igniting a full-blown epidemic. “Where Covid was seeded in the U.S. is not fully known,” she said, “but it wasn’t likely to have been a single seed.”
Alyssa Lukpat contributed reporting, and Susan Beachy contributed research.
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