Unexplained Respiratory Deaths Resource Repository Description

The Council of State and Territorial Epidemiologists (CSTE), in collaboration with the Centers for Disease Control and Prevention (CDC), funded sites from 2020–2024 to identify unexplained respiratory illness-related deaths occurring outside the healthcare setting. Participating sites included local and state health departments and medical examiner or coroner (ME/C) offices that developed and implemented protocols to identify and investigate unexplained respiratory deaths occurring outside the healthcare setting (i.e., at home, in the emergency department, or in an other location outside the inpatient hospital or long-term care facility setting). Unexplained respiratory illness-related deaths were investigated and Information was linked with existing ME/C information systems, public health respiratory disease/pandemic surveillance platforms, and vital records systems. De-identified core data elements for these deaths were shared with CDC. 

According to National Center for Health Statistics data (as of October 19, 2022), most COVID-19 deaths occurred among hospitalized patients, however 13% of COVID-19 deaths occurred in the emergency department or the decedent’s home (1). Similarly, analysis of supplementary data for decedents with COVID-19 in the early months of the pandemic from 16 public health jurisdictions revealed that among decedents aged <65 years, 8% died in an emergency department or at home (2). Identifying and investigating deaths that occur outside of healthcare settings is important because these deaths might represent severe presentations of COVID-19 or infections occurring in populations with limited health-care access or other factors leading to delays in seeking care. These and other deaths occurring outside the healthcare setting often fall under ME/C jurisdiction, therefore facilitating ME/C access to postmortem testing for COVID-19 and other respiratory pathogens could improve detection of deaths caused by respiratory infections and accuracy in death certification. Furthermore, improved detection and ability to characterize clinical and epidemiologic factors associated with respiratory deaths in this setting, particularly among persons aged <65 years, could inform prevention messages.

CSTE, CDC, and funded sites have created a repository of resources and protocols developed during the project. This repository will serve as a resource for a wide range of partners but is primarily intended for health departments and ME/C partners to reference. 

This repository is organized by participating site. It is important to note that each site has its own processes and specific workflows that have been summarized or shared. Types of resources contained in this repository include:

1. “Weekly Updates by Select Demographic and Geographic Characteristics.” National Center for Health Statistics, 3 November 2021, https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm#PlaceDeath

2. Wortham JM, Lee JT, Althomsons S, et al. Characteristics of Persons Who Died with COVID-19 — United States, February 12–May 18, 2020. MMWR Morb Mortal Wkly Rep 2020;69:923-929-929. DOI: http://dx.doi.org/10.15585/mmwr.mm6928e1 

Key Lessons Learned by State and Local Health Department and Medical Examiner Partnerships 

Sites participating in this project shared top lessons learned and advice for state and local health departments and medical examiner / coroner offices interested in similar work. The main lessons and advice to other sites are summarized here. 

Click here to view Top Lessons Learned

Participating Unexplained Respiratory Deaths Project Sites

1. Cobb and Douglas Public Health
2. Dallas County Health and Human Services
3. Minnesota Department of Health
4. New York City Department of Health and Mental Hygiene and Office of Chief Medical Examiner
5. Western Michigan University Homer Stryker M.D. School of Medicine (WMed) - Office of the Medical Examiner