Sites reported that open and effective communication was key to the success of this project. Communication was critical in all aspects (e.g., specimen collection logistics, database development/reporting, summarizing results). For example, in one site, funeral homes were willing to collect specimens and communicate with families after receiving clear talking points and directions from project representatives. In this situation, communication cleared up uncertainties and hesitations previously felt by funeral home partners. 

Sites reported that thorough training was essential to the success of this project. One site found that a virtual environment was optimal for training investigators, while another created a training pamphlet for investigators. These methods significantly decreased sampling errors and the number of samples that were not able to be tested. It was also noted that regular feedback to those collecting information was important for good compliance. One site lost the ability to monitor compliance for two months, which resulted in a temporary decrease in compliance. However, this improved again as soon as they restored monitoring and feedback. Coordinating specimen collection and transfer to the state lab posed challenges for one site since not all cases were seen by the state’s medical examiner/coroner (ME/C) office, but effective training allowed this process to become more streamlined and successful. 

Each site had different work roles and dynamics based on their local and state health department systems. The interaction between sites and with CDC partners provided important information that was taken into consideration and, at times, used to make operational decisions. For example, based on feedback from two participating sites, another site added postmortem testing to all cases that came to their ME/C office for exam. This was done for a period of time, until they had sufficient data to indicate this was not warranted in their site. Additionally, feedback from sites regarding increases in other respiratory viruses convinced another site to add testing using the Biofire platform as a routine practice in adult viral respiratory testing sooner than they otherwise might have done.

sites reported lessons learned from collecting swabs for testing and classifying deaths. The swabbing of decedents at death scenes was more logistically complicated than expected. Also, for many deaths deemed natural by the ME/C, there was no information available regarding the decedent’s signs and symptoms prior to death. Regardless of availability of this information, some of these decedents tested positive for SARS-CoV-2 or other respiratory viruses via postmortem testing. In these situations, it was often challenging for sites to determine the potential contribution of the virus to death, given viral infections can be coincidental (i.e., the death was due to specific natural circumstances that did not involve the infection). During this project, sites implemented postmortem testing for SARS-CoV-2 on every natural death occurring in the ME/C jurisdiction, and worked to streamline the process of swabbing, testing, and interpreting results/classifying deaths using site-specific, optimal processes. 

Lastly, optimization of information technology (IT) and fiscal logistics emerged as an important theme in the success of this project. Sites reported it was imperative to have an IT system that could efficiently capture, collate, and share pertinent data points with a site’s invested partner agencies. The monitoring of data during this project allowed one site to make appropriate operational changes at key points (e.g., determining which cases to swab and why). Another site struggled to move their data from an antiquated Access database and project REDCap database into their newly developed disease reporting data system. A considerable amount of time was spent discussing the needs of all programs with their IT team to make this move possible. Lastly, one site shared that fiscally, the accounts took a long time to be set up, which resulted in difficulties hiring project staff, and thus having to pull existing personnel to keep up on the deliverables of this project. Overall, sites felt it was important to anticipate and allocate appropriate time for potential IT and fiscal logistic hurdles. 

Recommended Tips for State and Local Health Departments and Medical Examiner Partners Interested in Investigating Respiratory Deaths Outside the Health Care Setting